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WELL PERMIT APPLICATION FORM 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 /> / ,� 1p�.rl \ Assessor's <br /> WELL Location-SIE <br /> r�4 \%, , <br /> Cy. YCross Street _\Me JU City Zip g531 (,P Parcel# p I <br /> PROPERTY Owner U 2n¢an Qro�,.tTS te % C�5 Address` /awl eo\1try�a Cu"ow � City4 n Ulw4vr% Zipl08 Phone# <br /> C-57 Contractor 2�� � Address 150 Aor.K, `Y cr City � '$W; Zip 44�S3 Lic#(o56V01 Phone#p %!; ' 3133J-51,$� <br /> Consultant / Sub Contractor ' C Addressson ]Ce�e�City'FMr "j1% Lic# Phone# -f l(o 841g:U <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(,NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) [] DESTRUCTION (choose type below) <br /> XSOIL BORING # Irl nn5 %Nf, [] OVER-BORE <br /> [] WELL # [] PRESSURE GROUT <br /> *Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS gg <br /> [] MONITORING [] HOLLOW STEM DIA. OF BOREHOLE r' 3 MULTIPLE CASINGS? [] YES ,JrNo WELL CASING DIA: ICL <br /> [] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS 1U L! TYPE OF CASING: [] STEEL [] PVC [] OTHER: 01 ;4e <br /> [] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL N TREMIE TYPE TO BE USED: [] AUGERS []HOSE <br /> [] AIR SPARGE [] PUSH POINT GROUT SEAL PUMPED: [] Yes 1[] N^o-(NOTES: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [] HAND AUGER GROUT SPECIFICATION NE.0."1 ly <br /> n <br /> [] OTHER: n avi`OTHER V.f \ APPROX. BORING DEPTH .7ee [] BOLTED TRAFFIC BOX or [] STOVE PIPE <br /> ,,�� ,,..,, <br /> CONDUCTOR CASING PROPOSED?� ( if YES, list specifications here) : <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> " CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x Title/Company <br /> Print Name Date <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By FF/ Date Issued � � Area f7 I <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: 671 � � '>&tc C P I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST If INVOICE <br /> SSG ) l rorpol l- l or SR# Grp t <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/ 12 /00 <br />