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cioZ <br />-C. <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <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 />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 />Assessor's <br />WELL Location 6FAC, Hwy qci Cross Street0-1-Ata5DAL(City LnD ( ZipSO Parcel# <br />PROPERTY Owner \IVOOV6(11DE..". elioe4ress C 39 Let:K.G124) Gr,city L zipWI/4Phone#Zo Z33 —fit 6, <br />Address 2 365— WV4DA itit City eS -VrT(Iltkip75-Lic#572-261)Phone# 16c-67/ C-57 Contractor P -O-C--1- 12-U 2. <br />Consultant / Sub Contractor Fa-Tr-ALL Ft1/4P IXEQ-iaddress /Z7'3 PA DDjC424(4ity L.bt Lic# I 75-2- Phone# 6a ce3 <br />GIS Coordinates: X , Y , Township Range Section <br />WO:5K TO BE PERFORMED: <br />WNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUN9H, HAND-AUGER, OTHER*) <br />*Other: <br />a SOIL BORING # ID F.' Z. <br />WELL # <br /> Grout Specifications: (_ _/J7-4 T3C-7 A_71— /U tv <br />I] DESTRUCTION (choose type below) <br />1:1 OVER-BORE <br />O PRESSURE GROUT <br />COMMENTS: <br />TYPF WELL INSyttLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ONITORING ,g/fi OLLOW STEM DIA. OF BOREHOLE 13 1/ MULTIPLE CASINGS? DYES fr‘:: WELL CASING DIA: <br />a EXTRACTION 1:1 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL fi<C- 13 OTHER:________ <br />o VAPOR [1 MUD ROTARY DEPTH OF GROUT SEAL 30 1 TREMIE TYPE TO BE USED: 0 AUGERS --K.- DS <br />, <br />0 AIR SPARGE 0 PUSH POINT GROUT, SEAL PUMPED: [I Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: CC ti,Z (-3-7— f- fi,-7 <br />0 OTHER: I] OTHER APPROX. BORING DEPTH ZoC) ' OLTED TRAFFIC BOX or f] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? N ( 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 h <br />County Or " nces <br />Signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />SITE <br />MITIGATION <br />UNIT IV <br />c c: <br />5e—i91 Ai Fo‘u <br />e prepare <br />nd Reg ations, and all applicable California State Laws. <br />is application and that the work will be done in accordance with San Joaquin <br />Title/Company Ci L E-A)(,e 4_9 E,Ciefib <br />Date <br />ued 511 0/CV Area <br />5/ Ittoi Final Inspection By I ( titnAcc-t., Date <br />c f <br />COMMENTS / CONDITIONS: / 0A II° S • <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D <br />BY <br />DATE PERMIT / SERVIC - • • T# INVOICE <br />/ . 3 S- e" a k 6/ a coicit _....,..., <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br />