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<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 />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />5,pplication 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 />< .---i . ,, — , Assessor'sjAo7L. <br />NELL Location P01 4._ 54,4.4- f --'04,1,Joabctiti 3( Cross Street 3614,...kf-ty(f .s4 City 51-0C/C---74rvt Zip Parcel# e."' 71- <br />elli 5./044497 Address City Zip Phone# ...... PROPERTY Owner e/ <br />C-57 Contractor Dr/74;4 Address 950 6Itit.. get City itilan4iN2- Zip C.f/ Lic# Phone# '?2,5- 3/3 -5-eco <br />Consultant / Sub Contractor edvtikY 4 ...,0414014(/• /6'.5 Address /SY Framic-110e5-6'1,YelCitySi-dChl-0-11 Lic# Phone# 7.0 7 -Z,3(1-0_9e57 .. <br />GIS Coordinates: X , Y , Township Range Section <br />.>•\ <br />O DESTRUCTION (choose type below) <br />fl OVER-BORE <br />liPRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: Atrc 08 G-r-rf jo )tt/e a- --Cakty <br />WORK TO BE PERFORMED: <br />U NEW WELL / BORING ( CPT, EOPROBE, HYDROPUNC HAND-AUGER, OTHER*) <br />:11.SOIL BORING4- (0 <br />0 WELL # <br />TYPE OF WELL INSTALLATION TYPE <br />U MONITORING U HOLLOW STEM <br />U EXTRACTION a AIR HAMMER/DRIVEN <br />0 VAPOR a MUD ROTARY <br />El AIR SPARGE 0 PUSH POINT <br />U SOIL BORING p HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES p NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL G PVC Ei OTHER: .11 0* <br />DcPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 13 HOSE <br />GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />Z... <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): N <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 Or ces, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company 4S-00e-:4 665(07:57VG(10Y - <br />Print Name M Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issued <br /> oczAre. <br />nal Inspection By Date <br />ECONDITIONS <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # E D BY DATE ERVICE RE• i LINVOICE <br />•• ' 0 0 <br />• 9ffL 1 ?2 419 00 411" . <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> Date <br />Date <br />C-57 WC -WAIVER C-57 Letter of Autho"iz4+or.v4o sign p rmi prrnrtrilm <br />