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Date Print Name ,t1A-90 <br />EPARTMENT USE ONLY <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />dooi.d HIJI ECVE89V6OZ TE:ET 000Z/VO/ZT <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 9-j5.3 d the S ndarg of,San Joaqtlin County Public Health Services. Environmental Health Division. <br />4-e-;;, ,, ,...c. c..,,,t,s--, Assessor's <br />WELL Location, ---..---- . rerActe-c,ppi- Cr c-sim-11 flellinai9aCitys5trY4 M .Ziin e VParcel# <br />_6, <br />A-1-- C. clrest ift9 0 -5 ('• 6 ' ' ----k\--: -- 11 " <br />e C-IC-41'V -P3*Phonet PROPERT r Owner ILCI <br />C-57 Contracto -, 5,;Ct-clei'1 - - Jdress6 j,t Ore---C---C iC-ki ittV-L CAP‘c _ ti 1 .119Q hone /C;) i --7g,-1/61•1 4- <br />Consultant / Sub Contracttra,S)71 ddresail vAlia-taity )v-ww to____ phtu1evy0 vb., 6b <br />. Y , Township <br />rr- <br />GIS Coordinates: X Range Section <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH. HAND-AUGER, OTHER") <br />f] SOIL BORING # <br />NWELL # 13 <br />"Other: <br />COMMENTS: <br />III DESTRUCTION (choose type below) <br />I] OVER-BORE <br />§' 1] PRESSURE GROUT <br />Grout Specifications: <br />CONSTRUCTION SPFCIFICATIONS <br />DIA. OF BOREHOLE 10 4 MULTIPLE CASINGS? I] YES a NO WELL CASING DIA: <br />ICh 1.4 TYPE OF CASING: a STEEL A1PVC [.] OTHER: <br />TREMIE TYPE TO BE USED: )4IAUGERS UHOSE <br />(NOTE- MAXIMUM FREE-FALL DEPTH IS 30') kA <br />1 <br />OLTED TRAFFIC BOX or STOVE PIPE <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 ances, Rule s Regulations, and all applicable California State Laws. <br />Signed x Title/Company _.7% <br />r r <br />TYPE OF WELL INSTALLATION TYPE <br />,MONITORING )HOLLOW STEM <br />n EXTRACTION [ AIR HAMMER/DRIVEN <br />I] VAPOR (]MUD ROTARY <br />fi Al R SPARGE II PUSH POINT <br />I] SOIL BORING HAND AUGER <br />OTHER: a OTHER <br />( 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 />CASING THICKNES <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: I] YAs <br />GROUT SPECIFICATIONS: V <br />APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Appkation Accepted By ‘---IY\ • <br />Grout Inspection By 1-1..Ani\rct--,,SJ <br />Destruction Inspection By <br />COMMENTS !CONDITIONS: <br />6 C-C-e-\+-ci- 4"et,Ct-fth <br /> Final Inspection By <br />Th <br />Date <br />Date <br />0 I <br />Area Date Issued Id / <br /> Date <br />ACCOUNTING ONLY: ONLY: AID# C# 'EA 0 0 S'b ‘ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK ft REVD BY DATE ' - ' OICE <br />1 4 1 V4 () -741-7- 611276 --L' Eatff 3 0 ( 1 - <br />SITE <br />MITIGATION <br />UNIT IV