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ariffrO Anal Inspect By <br />Date Issued <br /> <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />kpolication 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 />c, ..-"Nc %,•) k,At I - <br /> <br />cc o c.A.C.k.5,. Assessor's <br />NELL Location st....).. o,J), - (J0:•\i_ S Cmss Street City k 1/41c_tcf, Zip Parcel# <br />PROPERTY Owner C.- -'3 -,, c-)V-A,• Address City k c,14.,-, Zip Phone# <br />\....Pto-,-- ..\,‘,,y1 <br />G-57 Contractor zs-Nr4 _) c"-u.\\-`4 x--t Address %`>--t- \-k\ \c, Ci <br />t <br />ty ' Zip Lic# Phonee\ \ <br />Consultant / Sub Contractor <br />\o 11.1 4‘Q o <br />C.--\-,°5\. cc& tit-cA',^sckdSdress. \ \ \ -1- 4'-' S'I City (\(-\ 04.9.q.1-# — <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />B NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />11 SOIL BORING # [)OVER-BORE <br />tWELL # NNC-N-NNI % a PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />Phone 0 1 LI- 41\1 <br />County Ordinances, RulesitM California _Ilations, and all applicable Califo State Laws. <br />1-N,S\gk, Signed x zttl Title/Company /6\ 11_0-y- r , \)-..,/ 19)902J CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? fiVES fi NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS a HOSE <br />GROUT SEAL PUMPED: 0 Yes ji No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or flSTOVE PIPE <br />*COMMENTS: <br /> C- <br /> CONDUCTOR CASING PROPOSE?.______ (If If YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />TYPE OF WELL INSTALLATION TYPE <br />41, MONITORING U HOLLOW STEM <br />II EXTRACTION fi AIR HAMMER/DRIVEN <br />U VAPOR 1:1 MUD ROTARY <br />El AIR SPARGE 1:1 PUSH POINT <br />j] SOIL BORING a HAND AUGER <br />D OTHER: fl OTHER <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />n I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui <br />s <br />_s <br />Print Name <br /> <br />Date <br /> <br />DEPARTMENT USE ONLY <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />1 4 / Application Accepted By <br />Grout Inspection By WIW I= Date <br />Destruction Inspection By V Date <br />r (A <br />-- ------ --- - - - - - -_ _ — <br />ACCOUNTING ONLY: AID#, FAC# C 5-R0a-6/9-717 3) <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # C'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />350t Vi.o0 131-e._ iVzio SR* 3 0 3 L 3 <br />C-57 WC -WAIVER C-57 Letter of Author zati o sign permit Encroac ment oc <br /> <br />CO 39V8 <br />d0Old HIALd <br />EE17689b6OZ SS:ET TOOZ/8/Z0