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Date Issued
<br />Final Inspection By
<br />Application Accepted By
<br />Grout Inspection By f Date
<br />Destruction Inspection By
<br />COMMENTS / CONDITIONS: /
<br />Date
<br />112/1 .141V-10._
<br />ate 7.24 02-.
<br />ORIGINAL
<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 91115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division.
<br />WELL Location...,94/55 4C17C-6 ke-e_ Rue- Cross Street 6.'0. nek City S-Icki---101 Zip q-C'2° Parcel#
<br />Assessos . r'
<br />PROPERTY Owneraydr•ger--47"' OM-Address 1/245.N.a.Mth City 574,--A/ Ziple/Phone# 937.g341
<br />C-57 Contractor Gre53 (-,‘ Address qCc) City Plat I A Zip 9Y5:5-3 Lic#63-6 /O7 Phone# 311- 573610
<br />Consultant / Sub ContractorALLAc eLQ- 62ec, -..rtoccAfvle+4441Address V37 3K4L.,.., City Slict_Lion Lic# ‘ors'&07 Phone# (-16, 7- /6,6L,
<br />GIS Coordinates: X , Y , Township Range Section
<br />WORK TO BE PERFORMED:
<br />,NEW WELL / BORING ( CPT, GEOPROBE, HYDROPLACH, HAND-AUGER, OTHER") a DESTRUCTION (choose type below)
<br />.2,ff SOIL BORING # P -75- a OVER-BORE
<br />a WELL # a PRESSURE GROUT
<br />*Other: Grout Specifications:
<br />COMMENTS: s.he_ (,, (K E.,0- cc Li t-kss" ? 0J- , C • c 16--,e
<br />SITE
<br />MITIGATION
<br />UNIT IV
<br />OFF. eztOotti
<br />
<br />TYPE OF WELL INSTALLATION TYPE
<br />
<br />U MONITORING a HOLLOW STEM
<br />
<br />EXTRACTION a AIR HAMMER/DRIVEN
<br />
<br />a VAPOR a MUD ROTARY
<br />
<br />- a AIR SPARGE WPUSH POINT
<br />
<br />%SOIL BORING a HAND AUGER
<br />
<br />OTHER: U OTHER
<br />*COMMENTS:
<br />CONSTRUCTION SPECIFICATIONS —C
<br />DIA. OF BOREHOLE Z rA MULTIPLE CASINGS? a YES a NO WELL CASING
<br />CASING THICKNESS TYPE OF CASING: a STEEL g PVC U OTHER:
<br />DEPTH OF GROUT SEAL /619F -r TREMIE TYPE TO BE USED: a AUGERS fl HOSE::)
<br />GROUT SEAL PUMPED: If-Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30',
<br />GROUT SPECIFICATIONS: P °di
<br />APPROX. BORING DEPTH 100 c- T 1:1 BOLTED TRAFFIC BOX or a STOVE PIPE CI
<br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here):
<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 Ordi ces, Rules and Regulations, and all applicable California State Laws.
<br />Signed x / ,16. Title/Company 6rr., ton ore,: hi / 5,e't,,, i,S i' /'A. 'r 6 c c.
<br />Print Name CA,,,s4-06)1,,, k (k(.'lker Date
<br />DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADD
<br />WORK PLAN DATED:
<br />SS:
<br />
<br />"'zee-24
<br />
<br />Y: AID#
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK #
<br />r *AL,*
<br />REC'D BY DATE INVOICE -PERIM. CE R
<br />300 / .6.13 g? /2•7-60 det4" R# ooz6-77 _ • rs in—s int"
<br />C-57
<br />
<br />WC -WAIVER
<br /> C-57 Letter of Authorization to sign permit lncroacnriirii Coc_
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