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0' 2co SCI-Ig)u <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issued <br />inpl Inspection By Zr)) ?6C)/ Date <br />a d (;7/ ( Area <br />_.. <br />ACCOUNTING ONLY: <br />i <br />AID# <br />- <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RE t'D BY DATE ' - -.„..—• EST # INVOICE <br />/ I , 4 :. <br />c\-\ <br />Zo0 <br />iLqloyfie <br />/pc <br />6,t) <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />' 'irlLiiap <br />Date <br />Date <br />on) • <br /> <br />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 />-2-Qa 0 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />- <br /> <br />kpplication 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 /> <br />‘A • Assessor's <br />NELL Location .!) /,%--P. - C--(NS -\-Q-- V e.-- Cross Street %oc-oN.orl,; City CJ tOCA.acm Zip Parcel# <br />PROPERTY Owner 'sr-CL\ -P•ND'oN oxxx- Address k.%7---1 \N W.Glc c.-\,L,City V‘ Oc.,,V.k'vr% Zip ckS-ltri Phone# <br />c si - <br />C-57 Contractoro \Pi Q-\\ 'e-f,-,"' Address V (101.- S kc:k CitAk:sr OckA44 Zipc‘Clo a Lic# -1A61 Phone# c\.\.o - CtIQ L- cl 35 S <br />Consultant / Sub Contractor G '.\-- 'I._ Address -2-.-1"-\ \ K.\ 44Le 4 City rl. ,),k, Lic# Phone# I 3.1Y\ S1 <br />GIS Coordinates: X , Y <br /> <br />, Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) )(DESTRUCTION (choose type below) <br />0 SOIL BORING #D OVER-BORE <br />0 WELL # <br />I OilN't,r a PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: .tz,A C \NI eorsc..1 .r...--o\--..,o,.Vit..ak- .% \_cr..S 't ?g-c' frcl r'•0\-) \I\ S tt-k--\ (-`11/4(-1-- \ ••'-N fc\-1--k'',41 A - J c. <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />a MONITORING HOLLOW STEM <br /> <br />EXTRACTION U AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br /> <br />0 AIR SPARGE fl PUSH POINT <br /> <br />0 SOIL BORING fl HAND AUGER <br />OTHER: OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? DYES a NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL fl PVC OTHER: <br />DEPTFI OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />GROUT SEAL. PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS. <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( If YES, list specifications here): <br />Signed x <br />Print Name <br /> <br />(ON.('`nON.d`• <br />, <br />Title/Company V P <br />Date <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 Ordinarls?Ru s nd R lations, and all applicable California State Laws. r <br />DEPARTMENT USE ONLY <br />C-57 Letter of Autho i on tie- gn permit__ Encroachment doc_ C-57 WC -WAIVER <br />EEVE89VEOZ 9S:ET TOOZ/BZ/Z0 Ea 39d aooid HidIA