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Signed x <br />Print Name d 7 IP F <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 />SITE <br />MITIGATION <br />UNIT IV <br /> <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 9-1115.3 and the Standards of San Joaqui County Public Health Services, Environmental Health Division. <br />WELL Location() T <br />% <br />y 04..5(4.hTh ROO Cross Street..C* S:Ter..Y-76,0 Zip 15 241 Parcel# <br />1.1. Assessor's <br />PROPERTY Owner AAJ&PA- Address /536 AL City 53cie..Je..7e)/U Zip 95262, Phone#(1,99) /42443,4, )4/12.. G <br />C-57 Contractor ELKIZO Geoseickv..AsiivrAddress BP.Cuto wpp.i I S% 440 City 0Alear JUtl Zip 94/6a7 Lic#74120/.3 Phone#(5fo) Z107 -442.8 <br />PhoneitZs9)234-6.51,1- Consultant / Sub Contractorsremnnt. &EN buc Address Mg F2r,iliK liJAv CitYcne."-70sk.) Lic# <br />WORK TO BE PERFORMED: <br />(.A <br />NEW WELL / BORING( PTitt-OPROBO YIDIDUNCH HAND-AUGER, OTHER*) 5 Si T U DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER-BORE <br />0 WELL # 0 PRESSURE GROUT <br />-Other: Grout Specifications: -T-P& IA-GA/IAA/1/4.3r; L4irtirt).4-9/T.6- <br />COMMENTS: 5 cpr <br />GIS Coordinates: X , Y Township Range Section <br />CONSTRUCTION SPECIFICATIONS , <br />DIA. OF BOREHOLE /5" MULTIPLE CASINGS? l] YES NO WELL CASING DIA: <br />CASING THICKNESS A..VA TYPE OF CASING: 0 STEEL 0 PVC U OTHER: <br />DEPTH OF GROUT SEAL qA TREMIE TYPE TO BE USED: Opfait4S U HOSE <br />GROUT SEAL PUMPED: XYes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3O' <br />GROUT SPECIFICATIONS: A)AT _e•botnitir <br />APPROX. BORING DEPTH /SC <br />CONDUCTOR CASING PROPOSED? ,v,e) cif YES, list specifications here): <br /> <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />0 MONITORING 0 HOLLOW STEM <br /> <br />EXTRACTION AIR HAMMER/DRIVEN <br />0 VAPOR MUD ROTARY <br /> <br />AIR SPARGE <br /> XPUSH POINT <br /> <br />SOIL BORING <br />0 HAND AUGER <br /> <br />'OTHER: C-07 T <br /> <br />OTHER BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />'COMMENTS: A-7-7-6-vvv)7 S. CPT '51.4&i.iSi1ti4 STb 1--/ e_ept-L.A e2r /IAL.41-1r/pl-L ni2LDLIAJI11.4JA "rAi <br />"1-14-E C-AT Si ; AJO Son_j3,02JA9d, / Thy- c_p7- 5/Y 5 <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 Ordina ces, Rules and egulations, and all applicable California State Laws. <br />Title/Company 5-771fPF G 6-02-0c. 5 r <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> 4 <br />Grout Inspection By fliffie .4 At Date <br />Application Accepted By <br />llid <br /> <br />V <br />Destruction Inspection By <br />/CleFinal Inspection By <br />If/ v <br />COMMENTS / CONDITIONS. <br />( <br />Date Issued I V1 <br />ACCOUNTING ONLY: <br />-----,_-, <br />AID# <br />' <br />-R 120 313 17 7 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK #pfC'DATYL. PER ICE REQUEST OICE <br />5J7)1( Se ci, oo 671v4 ief). <br />pAlT/ <br />;le 0 3 3 0-r <br />\A i r _\A/ATVPD <br /> r-q7 I ottor n-F Atith i7nti cu-r1 er mit <br /> Fncroachment doc 9/27