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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 /> <br />ORIGINAL <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <br />NON-REFUNDABLE PERMITPERMIT 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 2 3 6CS-- -S Sonia. Fe_ RA Cross Street City P.V,Nrbi('1A k.ZIp 95-3c. 7 Parcel # 2-1-1 -010 00 / <br />PROPERTY Owner Troy Roe Address2-3 ‘C,S. -Sovi4‘ SCA IPA Feigity I:2 JeAci/I k"-. Zip '1S-36.7 Phone# <br />C-57 Contractor & e42.55 1)r-', N.5 Address q O 40vve. City Mari; &oz. zipq4s-'53 uc# 4 $516S-Phone# (11 313 -SVC° <br />Consultant I Sub Contractor SaCOR. kurwil Address 3017K ; "e )City Pttnct‘o tx,,--.M; 6102- Phone#(..it4s0 '1.$10D <br />GIS Coordinates: X . Y ,Township Range Section <br />WORK TO BE PERFORMED: <br />)NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />)21.SOIL BORING # CP <br />0 WELL # <br />*Other: Grout Specifications: <br />DESTRUCTION (choose type below) \.0 <br />0 OVER-BORE <br />PRESSURE GROUT 6' <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[3 MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2-" MULTIPLE CASINGS? [3 YES [3 NO WELL CASING DIA: \f‘ <br />I] EXTRACTION I] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [3 STEEL 0 PVC 0 OTHER: <br />fl VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 6s-1 TREMIE TYPE TO BE USED: El AUGERS 0 HOSE <br />r] AIR SPARGE %PUSH POINT GROUT SEAL PUMPED: (3 Yes I] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') -.1--\ <br />%SOIL BORING [3 HAND AUGER GROUT SPECIFICATIONS: C6 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH ,-C- / 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />-- CONDUCTOR CASING PROPOSED? ( 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 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, R les and Regulations, and all applicable California State Laws. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: .3569S Sez-s.-, /e <br />WORK PLAN DATED: 0 / <br /> <br />Application Accepted By <br />Grout Inspection By <br />Signed x <br />Print Name 'Jac- AUCI‘i-fr too\ e <br />iSt/S:e.:CGR- ACCtfl Title/Company 5-12A‘lOr Geolc <br />Date St)..-1/01 <br />Date <br />Date Issued /61-'1 - 0/ <br /> Final Inspection By <br />Area Area a-4W <br />Date 7- 2.4 -6 2- <br />Destruction Inspection By <br />COMMENTS 1 CONDITIONS. <br />Date <br />— - — <br /> <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE P : Li I ' UEST 11 INVOICE <br />3) 55 Eer, ,.-- c0506 aeA 5)- . (2O <br />C-5 7 WC -WAIVER C-57 Letter of Authorization to si n erm Encroachment doc 9/27/00 <br /> <br />CEVE89V6OZ TE:ET 000Z/170/ZI 60011 I-LUI_d E0 39Vd