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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> <br />304 E. Weber, Third Floor, Stockton, CA., 95202 AEcE <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB 0 5 ZOOZ 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 Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Service y4rpamentali.Heatth,l1Divasion. <br />'=-1. I n U wAiiesbiiiqL I n WELL LocationsK 'VI- Pt ,k: --1.,c,-4,- X Cross Street (2)(5.ii.i,vie-u. kJ City ; er..C-i_ zip PFRMITOgiiCES <br />PROPERTY Owner CAA-Utz: Address h L. U d ' City (64.3(_14._kb,‘ Phone# 61(13, .12 B <br />C-57 Contractor Vie,tvo,, c4,-1)1:1 Address 14 Oc- S. 5 s-1-t. gire.o.+ City )Vi•-.41,2, Zipil 4( 0 41 Lic#0367F Phone# , 2-31. 4S1S- <br />Consultant / Sub Contractor I f Address 19_14&i OrtcLitc-ct- (v.t Cit/ALA, 441,16.6 Lic# Phone#1(6. fla c 4-1 g 5 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />-- a SOIL BORING # <br />WELL # <br />*Other: Grout Specifications: <br />COMMENTS: <br />SITE <br />MITIGATION <br />UNIT IV <br />DESTRUCTION (choose type below) <br />OVER-BORE <br />PRESSURE GROUT C/1 <br />TYPE OF WELL INSTALLATION TYPE <br />a MONITORING fl HOLLOW STEM <br />a EXTRACTION U AIR HAMMER/DRIVEN <br />VAPOR flMUD ROTARY <br />U AIR SPARGE g PUSH POINT <br />I SOIL BORING U HAND AUGER <br />OTHER: U OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE Z in MULTIPLE CASINGS? a YES I NO WELL CASING DIA: <br />CASING THICKNESS no rle. TYPE OF CASING: fl STEEL a PVC a OTHER: <br />DEPTH OF GROUT SEAL ID:- TREMIE TYPE TO BE USED: fl AUGERS I HOSE <br />GROUT SEAL PUMPED: a Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') r <br />GROUT SPECIFICATIONS:'', 21.5 t; <br />APPROX. BORING DEPTH lc c) BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (lc, ( 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company Vrfl , (1 <br />Print Name Ackes.x- At-Uc.rn- <br /> <br />Date <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: `LS ";- („,—( 5 -in_e_e7A <br />WORK PLAN DATED: -1-0,0 7_00 z <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection <br />Date <br />Daft <br />1 <br />Date Issued 9% ) TIr Z _ Area <br />-r_, i sto -z_Final Inspection By t_eDate <br />COMMENTS /CONDITIONS <br />ACCOUNTING ONLY: AID # <br />FAc# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE T1E-ST # INVOICE <br />35-Q1 C,Scf ,0 0 1 q <-2- (Ak 2-1).7/Z- SR# c,l-c O'cl, <br />C-57 <br /> <br />WC <br /> <br />-WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />9/27/00 <br />