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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 />ORIGINAL <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 />r7 /�/--� e, Assessor's <br />WELL Location f/4ti'���,'S� . Cross <br />�Street°%K' -1-f City�QA j' / _'� Zi %'L!� Parcel# 1�e,;1 ('.�>-D�l <br />li <br />PROPERTY Owner CS Y� W_ .$.tt� � 6 ,. .dress O �� 1 7 f `" City 65 "�45ZippIKO, hone#, <br />�t `L v p �1 <br />C-57 Contractor, ��`2�3(t�11� \�`��1 AressRT[ �- Cit ,Zipla�7�'� Lic#hone# -� <br />Consultant/ Sub Contractottt�tTcTr&)[Yli1 Address C (? Citil7�Lic# Phone#o 2. , l-64.6 1) <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDRO_PUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />_;aBOIL BORING # C' (� - ( (i �-1 OVER -BORE <br />0 WELL # [] PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />E AIR SPARGE WUSH POINT <br />0 SOIL BORING, 0 HAND AUGER <br />OTHER: �_ 1 1 0 OTHER <br />'COMMENTS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE a °r" MULTIPLE CASINGS? 0 YES- NO WELL CASING DIA: <br />CASING THICKNESSQATYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 19-0 TREMIE TYPE TO BE USED: 0 AUGERS ��iOSE <br />GROUT SEAL PUMPED:ifyes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Y!1CtyY_)= <br />APPROX. BORING DEPTH l0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County manceRules a d Re ulations, and all applicable California State Laws. <br />� %rte <br />Signed --yam Title/Company ��'F,-t1- y''Anf) <br />Print Name- ( "T 1 n gra t �► ITi L L� �j Date I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 33 (4 <br />WORK PLAN DATED: (0 (I b <br />Application Accepted By Date Issued ( �'� ✓ Area / 2 -- <br />Grout <br />Grout Inspection By Date Final Inspection By Date .57-/6 <br />Destruction <br />COMMENTS / CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# Germ <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />350 1 <br />0 Ci� <br />� (a <br />6 -77&3, SR# S <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit E 9/27/00 <br />s6kuu 3- S4 <br />