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WELL PE 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 />if (209) 46S-3449 <br />No .REFUNDABLE PSRM1T ExPIRES i YEAR FR M D Tr ISSUED <br />i llc;rnlslemacet: T <br />..7.quiVI.u14rpermit:Ttuct andiorinsJ he ee 1.Trus vas is neZnzr rc7vih San <br />olc,rcuntycrieloprret3glap 153:nctnen elserijcaq Co <br />unty=1thr,cnrmerivis0 <br />Assessor's <br />NELL Location 40( m , S,7 44C•16vi crass strew _E;(4w 4acit9 Cit0-1-h, Zip ParceI# 1 1 5- - /0 <br />PROPERTY Chriner <br />----APcItess City 5?4(2,4t-41.417 lp 9V4,2honeer 9/0 - q7Z -51- <br />C-57 Contractor o,-_DI._IL__..'CE1.--.../I`N-AoreA,444dres3.2_:_Ljaa,,.:-2 5-1----5 Dltye_2.1p.;?S-Gte2-ListO Pnone#LTI,- qqo --i, 333 <br />Consultant / Su o Contractor.0:---Address e 02K- CityluLr.,2 %_—Lic"Phone# 530 -Oft :SI OD <br />*-1/aS <br />GIS Coordinates: X 3 7°57. 251,0N , y122_a_11.4Z-1--° , Township Range Section <br />a NEW WELL! BORING ( CPT, GEOPROSE. HYDROPUNCH, HAND•AUGER, DTI-IER`) <br /> <br />30 ESTRUCTION (choose type below) <br />c SOIL BORING # <br />DOVER.BORE <br />i •RESSURE GROUT INDFI EDI. <br />B WELL # Grout Specifications: ....• II \ . ....t.a th. <br />°Other: <br />COMMENTS: <br />TYt:JE oiI---WE L INSTALLATION TYPE CONSTRUCTION SPEoLFICATIONS <br />D MONITORING D HOLLOW STEM 01A. OFBOREHOLE MULTIPLE CASINGS? c YES 13 NO WELL CASING DIA: <br />1] EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS <br />TYPE OF CASING: El STEEL 0 PVC (I OTHER: • <br />D VAPOR 0 MUD ROTARY InPTH OF GROUT SEAL <br />TREMIE 'TYPE TO BE USED: n AUGERS c HOSE <br />13 AIR SPARGE 1:1 PUSH POINT GsoLrr SEAL PUMPED: D Yes C No (NOTE'. MAXIMUM FREE-FALL DEPTH IS 30' <br />0 SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS: <br />TRAFFIC <br />a OTHER: OTHER <br />APPROX, BORING DEPTH 1] BOLTED BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( It YES, lit speacatlens 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 />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 <br />all appiicabie California State Laws. <br />Title/Company <br />Signed x <br /> Date <br />Print Name <br /> DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Appiloalion AccePted Sy <br />Grout Inspection By <br />Destruction thsoection By <br />, _ <br />11/16611127 <br />C-57 WC -WAIVER C-57 Letter of Auth• <br />eisteffflrf permit Encroachment dor. • 9/27,t0C <br />SITE <br />MITIGATION <br />UNIT IV