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WELL PERMIT APPLICATION FFURM 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 <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 /> WELL Location -5/qt/. 6mg/R Cross Street (_I NGL0GN ! !— Ci Assessors <br /> CA <br /> ' \ ty ✓(T�G�j a�/ Zip�Parcel# ��� Ri6�/�Ft✓,Q� <br /> PROPERTY Owner_.nay 0,r py Address y2��•f.���a1o►�p' SfCity 5EGY�T� Zip7�0ZIPhone#_� <br /> C-57 Contractor 6A5�02-, BRILL%f/6 Address 3632- G 713.5-1 a <br /> 1R City GoRDO%4- Zip Lic# Phone#yI6 63�-116�f <br /> Consultant/Sub Contractor 5#,44 Efl/ I(/G Address 1326 Al /`1/4-1Tif0,,TWCity 5/¢L/3q✓ns' Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> AMIELL# /41 W-3 R 0 PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �vIONITORING ,HOLLOW STEM DIA.OF BOREHOLE g n MULTIPLE CASINGS?0 YES RNO WELL CASING DIA: Z� <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS-';--# yd TYPE OF CASING: 0 STEEL eVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ^- /// TREMIE TYPE TO BE USED: fl,�AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 66v,"0--r 6 VL1'T <br /> 0 OTHER: OTHER APPROX.BORING DEPTH 3 a/ OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 'O/i/ (if YES,list specifications 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan , R es and Regulations, and all applicable California State Laws. ( j� l <br /> Signed x I^ /� Title/Company C.cAsc a 6 e -✓ Irl 1 t I <br /> Print Name U e r� ► l�ii I✓ ��C, (-\ Date _021 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S( K W. 694ET E L✓i4;( <br /> WORK PLAN DATED: 4 P/?/ I?- , 2,-Pc->z_ <br /> Application Accepted By Date Issued O Area <br /> Grout Inspection BDate c _ r. Final Inspection By ( ;c��,- v. Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �s0 ( (a oma' zZ G� 3 a SR# 332- <br /> S�� <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />