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75' n, <br />r,_ <br />WELL PERMIT APPLICATION FORM <br />WC C-57 -WAIVER C-57 Letter of Authoriztion to sign permit Etroachmen (..} <br />SEP 26 7 1AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONEI HLI- ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />PERMIT/SERVICE 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 /5 146 6.• reicy /3/....VD Cross Street i-7iliviai 4 City S-ree-&-r(NAL Zip Parcel# /87— /7-0 7 <br />PROPERTY Owner56S ickfil-A-04-A Address (11166 < 74eier OW City .0-terdh-1 Zip • Phone# <br />C-57 Contractor &in& PIOISE, Address55IS- i- A4‘411-0/14A SI— CitYPINIA141/14 ZIP?apec, Lic#6&227 Phone600) 00 5q5 3 <br />Consultant! Sub Contractor (Wilk& arr.6641411U,M6,7*Address 737 Sith-L) V-0A-6 City "7-aUl-,T4W Lic# &viz 7 Phone#0047-4a, <br />Range Section <br />WORK TO BE PERFORMED: <br />kJ NEW WELL / BORING ( CPJ'rdE(S-PROBE, HY-OROPU,NCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />'11-5-011L- BORING-# - B OVER-BORE <br />0 WELL # B PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />1Z <br />N/111-1-1 6-9-Ai T. <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 Pr, c s, R les and Regulations, and all applicable California State Laws. <br />Signed x Title/Company E'7 \ E &T keLhert.5--/Apti, 6-reo)ch1pi,o.vA,tk1tj7:44 <br />Date 09#41/0i <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />• <br />Date <br />Date <br />Final Inspection By: <br />L. Date Issued Area <br />ate 1/I) /0 1 Application Accepted By <br />Grout Inspection By <br />Destruction Inspection t., <br />V.,. MMMMM ...MO , —......--........_. <br />ACCOUNTING ONLY: AID# FAC# _ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE VOICE 1,PE1MIT / SERVICE REM-L-5'54c <br />rr '7\ <br />GIS Coordinates: X , Y <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />0 AIR SPARGE ti PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />1:1 OTHER: 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2' MULTIPLE CASINGS? 0 YES NO WELL CASING DIA: /\fA <br />CASING THICKNESS WA TYPE OF CASING: B STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL-ToTAL DE?77.J TREMIE TYPE TO BE USED: I] AUGERS y HOSE <br />GROUT SEAL PUMPED: 11.Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ce0 a_17-11/0> _L <br />APPROX. BORING DEPTH —IS' / U BOL ED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ki 0 ( if YES, list specifications here): <br />*COMMENTS: t L- 4.--)a-bt-VAS 0 AfTem6144.4:1 71, Ly 4041 la g-Aad-7/_62.6. <br />?AL <br />, Township <br />Print Name <br />SITE <br />MITIGATION <br />UNIT IV <br />t.i <br />DEPARTMENT USE ONLY