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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location (ACM( <br />Assesso s <br />1-4 v/ f,4-Cross Street LW.. /0e/A Zt' City ...4efavi krotpfzip 45337 - 14-- 13 Parcel# <br />tsCc: <br />Phone/ <br />In - 5,froo <br />GIS Coordinates: X <br />SITE <br />MITIGATION <br />UNIT IV <br />PROPERTY Owner &AP/ 5t--)X1r-1 Address City Zip <br />C-57 Contractor frel, Address 95,0 phae toqd City fiku441.. Zip 033 Lic# Phone# <br />) <br />9U —e - <br />Consultant / Sub Contractor se, e.te r„, Address 20c6 td, rin/A do ki City autA k Lic# Phone# ft° 939/ <br />,Township Range Section <br />G DESTRUCTION (choose type below) <br />13 OVER-BORE <br />0 PRESSURE GROUT <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # (pf- 769 <br />a WELL # <br />*Other: <br />COMMENTS: <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />13 MONITORING G HOLLOW STEM <br />a EXTRACTION AIR HAMMER/DRIVEN <br />13 VAPOR 13 MUD ROTARY <br />O AIR SPARGE 0 PUSH POINT <br />G SOIL BORING 13 HAND AUGER <br />a OTHER: G OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 1.° MULTIPLE CASINGS? DYES 1:1 NO WELL CASING DIA: <br />CASING THICKNESS Aiti TYPE OF CASING: G STEEL U PVC 0 OTHER: <br />DEPTH OF GROUT SEALI)ItAl cVef ft TREMIE TYPE TO BE USED: 18.AUGERS G HOSE <br />GROUT SEAL PUMPED: ,Yes G No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: /v/44' <br />APPROX. BORING DEPTH HO ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Afil ( if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinance s and R- • ulations, and all applicable California State Laws. <br />Or <br />Signed x arr <br />/ <br /> <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: .J-‘5 \--- a01(), aSo <br />WORK PLAN DATED: <br />Application Accepted ByCs:)C4-• Lr...)44K--- Date Issued :!.7L)--1 'D ( Area <br />Grout Inspection By 0, c4- L ..• (-43. 1---,c),A.....„ _ Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMEN1 b / UUNUI I IUNQ: <br />ACCOUNTING ONLY: AID# - FAC# - • - <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT /ERVMC -REQUEST # _ <br />---', <br />INVOICE <br />3 60 14-cETIv C,i,-.) 61 ._-_--,1,, ,,, t.:& , , &-, 343 ti, : : 41 0, A • <br />^ in /17 /An <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permi ncro • <br /> <br />DEPARTMENT USE ONLY <br /> Title/Company/?'-t /770/10,e, 6>reealti÷ 1.• <br />Date aa./0/