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ORIGINAL <br />SITE WELL PERMIT APPLICATION FORM <br />Township Range Section GIS Coordinates: X , Y <br />"Other: <br />COMMENTS: <br />Grout Specifications: <br />*COMMENTS: <br />APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( If YES, list specifications here): <br />- <br />Print Name Date <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES WEN itYl TV41,PON <br />CcAc0(0-7—-. S44Q ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 954S2SEP 23 z\DTN--4A.e (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />NpplIcation 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 />,:ii-eir-, Assessor's <br />NELL LocationC •'c 1 ,\MCni\kiz c. c-\ s-iii.,,suit Cross Street V\0‘.V\ City c\i\ell\k- Zip Parcel# <br />PROPERTY Owner C...,Nik -) OVC\olse\k-t-Pp. Address \\Vo \ \i City \\N;v4ea Z' ip <br /> <br />Cf'53-7Phone# <br />C-57 Contractor C-2) f_OiaQi) Vi\-;1\ -1ddress;\..SP \\,,,..1.52.. 9L--iii City i.t ZipC Li \*S52 LkiS")5 q <br /> <br />c# Phone# <br />Consultant / Sub Contractor C-, sLZ \ i4cS, csiji- r /C.- c ‘A‘id.\-\d -r:sSli \ \ \ --\ '0---\ City ril<Jrfi, Lic# Phone# ?.., 0 ck S 2_ -2-4)) 9 <br />El DESTRUCTION (choose type below) <br />fl OVER-BORE <br />[] PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE V( MULTIPLE CASINGS? a YES a NO WELL CASING DIA: <br />CASING THICKNESS --- TYPE OF CASING: °STEEL El PVC 0 OTHER: Z <br />DEPTH OF GROUT SEAL '-‘ SO' TREMIE TYPE TO BE USED: []AUGERS a HOSE <br />GROUT SEAL PUMPED: El Yes fl No (NOTE: MAXIMM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ,----X.e.-4A-4/ <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 man s, Rules and Regulations, and all applicable California State Laws. o 'C <br />Signed x *V\a-Q/z_12._ TitleJCompany <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: f6) Ai• 1') <br />WORK PLAN DATED: I - 0 <br />Application Accepted By <br />Grout Inspection By I. . Do l\SCh,1 <br />Destruction Inspection By Date <br />-- .... --- - - ------ --- 'I <br />ACCOUNTING ONLY: <br />.0 <br />AID# . FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # 1;!..FD BY DATE # INVOICE <br />61/0- 61,44-- ?r ,- SR* <br />. ,- .......—...... <br />P 37 <br />0 M. <br />C-57 ,t,(-VVC /-WAIVER <br />CO 39Vd dOOld HIALd EEt7E89V6H 9S:ET TO03/8/Z0 <br />C-57 Letter of Authorization to sign permit oac ment do,çJd <br />eat 46 ,/ <br />WORK TO BE PERFOR E <br />WNEW WELL / BORIN 463;17 EOPROBE, HYDROPUNOMAND-AUGER, OTHER*) <br />1.1111w-i SOIL BORING # <br />u WELL # <br />TYPE OF WELL <br />O MONITORING <br />a EXTRACTION <br />a VAPOR <br />O AIR SPARGE <br />[1 OTHER: <br />INSTALLATION TYPE <br />a HOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />a HAND AUGER <br />[I OTHER