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WELL IPERMIT APPLICATION FORM <br /> SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W NIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton , CA., 95202 <br /> (209) 468-3449 �c? <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' / a <br /> Application is hereby made to San Joaquin Countyfor a permit to construct and/or install the work described. This application is made in compliance with Sen <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 i;9 � o 1"'� : � < 1 Ye�& . e Cross Street r +'���-' vr, city Stv - 1;/�-,r zip fx' -2 Parcel# oE+ t 3bo . oY <br /> PROPERTY Owner R+ klro k <br /> �ntz poxarc Address fs"2& //K W< 7`er ffi: Cityr Zip �.�'�ce/ Phone# <br /> C-57Contractor L+r ( ' Address ql� A, Clty LZL IywcZ Zip9Y hone# 9-?f <br /> ! Bn r✓a�KV✓etcrvc(N <br /> Consultant / Sub Contractor Co.9Sz-r E'z.,�f Lr %.=c.G, Address fc = City Sr K rte., tic# Phone# 2� Z3'V o6 S <br /> GIS Coordinates: X , Y., Township Range Section <br /> WORK TO BE PERFORMED: — <br /> RNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE <br /> �'W ELL # I 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? BYES IrNO WELL CASING DIA: ✓( <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS Yo TYPE OF CASING: 0 STEEL NPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -Z2 ✓ TREMIE TYPE TO BE USED: KAUGERS 0 HOSE <br /> 0 AIR SPARGE p 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: /l/ ea/f C e✓ eer7- <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH `I.r ✓ , BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (Vt> ( 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OrdAnances, Rules and Regulations, and all applicable California State Laws. <br /> Sinedx � �i t Title/Company 8 '�l�✓ /�/ <br /> 9 <br /> Print Name �-N ecf Dateo/'e-�, �zz ✓ !® dZ.� v/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> Application Accepted By / \ \1 ate Issued / / C L Area <br /> Grout Inspection By u Date (' Final Inspection By. Date <br /> Destruction Inspection /y Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVr <br /> 01 1 Q0 I T �Z y Zgt2 c, <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth izafo o sign per Encroachment doc_ <br />