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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 />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR_EROM 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 r iade inccrnpliance with San <br />Joaquin County Development Title, Chapter S-1115.3 and the Standards of San Joaquin County Public Health Services, EnvIror rental Health Division. <br />Assessor's <br />WELL Location ?-1(90(...3.0-504.Akok4rov4_ Eci Cross Street :1-11- 5 City 161-1-1 Z]p Parcels <br />PROPERTY Owner Baru ,e4 0_01-? AddressfiC42..SLraeti LT. Oitv Sitalorm Zipq521Ct Phone <br />C-57 Contractor Adcress It S'ATtr--+ CItyl"Sit+tx#1, Zp Lott 120 c1OLI PnoneSN it )) 711- 14100 <br />Consultant / Sub Contractor‘rrnpuld 2, co Address 1,1111 VIAA:inp Sired- City ..,cr•ttut-1/4. Li: # Phone#(24CI) 83S-4(1W <br />GIS Coorcinates: X Y ,Township <br /> <br /> Range Scr Secttr <br /> <br />WORK 1-0 BE PERFORMED' <br />0 NEW WELL I EORING (CF, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') I] DESTRUCTION. (choose type below) <br />0 SOIL BORING # 0 OVER-BORE <br />ircVELL # PAW I -firtxtrgslor. VvtuOirt 0 PRESSURE GROUT <br />-Other Grout Spedlications: <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />XODNITORING XHOLLCW STEM <br /> <br />EXTRACTION fl AIR HAMMERDRIVEN <br /> <br />VAPOR 0 MUD ROTARY <br /> <br />AIR SPARGE flPUSH PONT <br /> <br />['SOIL BORING 0 -IAN:, AUGER <br /> <br />0 OTHER: n OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CAS NGS7 0 YES 0 NO WELL CASING DIA: .2 Ink-k <br />CASING THICKNESS Sch Li 0 TYPE OF CASING a STEEL )31,pvC C OTHER: <br />DEPTH OF GROUT SEAL 3 Petil- TREMIE TYPE TO BE USED: a AUGERS HOSE <br />GROUT SEAL PUMPED: a Yes ,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: hAA-k- r,emokii. "-VS% 6cA14114E <br />APPROX. BORING DEPTH q cCt 1(C3OLTED TRAFFIC BOX or D STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ‘,3 6 (:1 YES, list spec.fIcations here). <br />*CCMMENTS: <br /> <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 />County Ordin ces <br />Signed x <br />Print Name <br />I hereby certify at I h ared this application and that the work will be done in accordance with San Joaquin <br />ules d Regulations, a I applicable California State Laws. <br />Tit e/Company SiltH 4tZ3Z574 7,PrO <br /> Date 4 <br />DEPARTMENT USE ONLY <br />gfrfra,e <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Grout Inspection By Date Final Inspezdon By <br />Destruction Inspection By Date <br />COMMENTS / CONDMONS: <br />Application Accepted By /4)k,,,17L Date Issued <br />---r- <br />ONLY: AID# FAC# , ACCOUNTING <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT ST 0 INVOICE <br />- 06 7 o2— 1:144--+ if/A <br />1,1 04e, 2-40 6 1 <br />- - ..... <br />C-57 <br /> <br />WC -WAIVER <br /> C-57 Letter of Authorization to sign pv-rnit oc