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WELL PERMIT APPLICATION FORM <br />SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 — <br />(209) 468-3449 \WED <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 lisEtguNi);16c4 iwith San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,.Enviranmental Health Division. EIV <br />t 4— 170-1Z w-7 <br />ZIP 9524 OPhone# 9 -477 / <br />i\-(1 Address $37 (5itscA,o Ed city5loc Oar Lic#66'0.227 Phone# 1b7 -J1t. <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />pcJEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') fl DESTRUCTION (choose type below) <br />SOIL BORING # G OVER-BORE <br />*WELL # 1volp.AR fl PRESSURE GROUT <br />*Other: Grout Specifications. <br />COMMENTS: <br />WELL Location,212 0 V\i Tyr e r p.c f <br />PROPERTY Owner RObei 4- MC enr <br />C-57 Contractor 114-14-C ."42- .kNAt yk-Ci Address 53100 "5. Wet+ V- A-VQ. CitySetcectmsitiozip 95-2bLic#67.26/ 7 Phone# 9k-63/ —3-s8,3 <br />Consultant / Sub Contractor <br />Cross Street Dr City Lo ci Zip 9 QT-1441Frn-f. c ES <br />Address D1 IA) Sck P_Ct City L, cx-11 <br />Date Final Inspection By t' 1" `-- <br />Date Issued 1/2.-1 Area 1-'1-:)P <br />Date <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE ,f3 ,2,s- MULTIPLE CASINGS? YES X10 WELL CASING DIA: X.- <br />CASING THICKNESS 3CL40 TYPE OF CASING: II STEEL VPVC G OTHER: <br />DEPTH OF GROUT SEAL .,-3D TREMIE TYPE TO BE USED: ,AUGERS U HOSE <br />GROUT SEAL PUMPED: B Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 004-1 cmAtA <br />APPROX. BORING DEPTH I trBOLTED TRAFFIC BOX or G STOVE PIPE <br />CONDUCTOR CASING PROPOSED? QL) ( if YES, list specifications here): <br />*COMMENTS: n'k tA 111-5 c_ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />'MONITORING %HOLLOW STEM <br /> <br />EXTRACTION AIR HAMMER/DRIVEN <br /> <br />VAPOR [J MUD ROTARY <br /> <br />G AIR SPARGE fl PUSH POINT <br /> <br />G SOIL BORING fi HAND AUGER <br /> <br />[J OTHER: QOTHER <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 />Count rdinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x R v_ SI_____Q__A, Title/Company (.-91 t`',/ )1 C9 Jr, I--- 1 Ot-CE <br />Print Name 0%r-1 i -e 1 Kec. \ WL L a Ckf\• Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By k/1"-4.-1-4 <br />Grout Inspection By riA-4—"e <br />Destruction Inspection By <br /> Date <br />• <br />ACCOUNTING ONLY: AID# FAn# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ERMIT / SERVICE RE , T # INVOICE <br />75 - i'-i't C.) t'l--- tik-3/ R# 0031.--2- 7 • , _ 1,, inn <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit_ <br />