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WELL PERMIT APPLICATION FORM"L <br />SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ON - 9 t 1 p <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 Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location 15 fes, OZAQr; Cross Street ` rr,4;�) City J i ��c "�`k_CtN.� Zip q Parceell# n1�t' I <br />PROPERTY Owner ICAC© �" AgLA(A.1 � Address 1 /Ii # �ty. eQ-t UiL(l� Zip (6�Phoj#,- 1' - 9 I <br />C-57 Contractor��� �!!( LNG�ddress (o3Z. i l�1YC . City R Zip/ Lic#7%A7O Ph ne# & 3S-- /`(O <br />Consultant/ Sub Contractor) T 0 0 J -)QJ Address) (p Iy MAC,t 1(}iiy L Lic# Ph e# Ze-3- D <br />GIS Coordinates: X <br />R <br />Township <br />WORK TO BE PERFORMED: <br />gNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />[] SOIL BORING # <br />vvELL #g . `1 GWiG _ I O <br />'Other: Grout Specification <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[MONITORING <br />EWOLLOW STEM <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />[] VAPOR <br />[] MUD ROTARY <br />[] AIR SPARGE <br />[] PUSH POINT <br />[] SOIL BORING <br />[] HAND AUGER <br />[] OTHER: <br />[] OTHER <br />'C <br />Range Section CvX <br />[] DESTRUCTION (choose type below) 4J <br />[] OVER -BORE <br />[] PRESSURE GROUT \ <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE >� I I MULTIPLE CASINGS? [] YES �XNO WELL CASING DIA: 11 <br />CASING THICKNESS_ TYPE OF CASING: [] STEEL PVC [] OTHER: <br />DEPTH OF GROUT SEAL C1S1 TREMIE TYPE TO BE USED: [AUGERS [] HOSE <br />GROUT SEAL PUMPED: MYes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: �L"Y IAry 6 CCrr4N-, <br />APPROX. BORING DEPTH a O i %BOLTED TRAFFIC BOX or []STOVEPIPE <br />CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <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 certif that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordina ces, Rules and Regulati ns,/a�nddlall applicable California State Laws. <br />Signed x L^� CSU Title/Company �/ <br />Print Name o <br />DEPARTMENT USE <br />�ONLY <br />/ <br />SITE MAP IN UNIT IV FILE, ADDRESS: (N y 2-N� �-�C A44 <br />WORK PLAN DATED: ` O <br />Application Accepted By Date Issued Area <br />Grout Inspection By Date al Inspection By te_ <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />P EST # <br />INVOICE <br />3s0 t <br />j <br />8i3 0 <br />5 J, <br />C-57WC-WAIVERS—r C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />