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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS -EHD) <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 /> nf1 qq r� Assessor's <br /> WELL Location 6.2� fck -tiic- HVG. . Cross Street Porro Ave . City �f'ot-ICC' Zip Parcelel# O$ 1 - 3606Z{ <br /> PROPERTY Owner 'ejej4 r Nlttr.o.rt (te.r¢�Address 1153G n( i4vyy 2. Sf City S'focK.to v� ZipRs 4 PhoTreaq#��7'}'1 "- 5sJ5 <br /> C-57 Contractor V+ '(k) lJr • 19rw.:, SNr-Adddrre-ss 100 P7vV +-1, �tYezt City1.SI Lo.n Zip 41 SZM I Lic#7a o9a4 Pho�ge% <br /> Consultant / Sub Ccntractoco_V_4 r &rti'l C'C,kt aCAddress 1786 ro.^k- LofsCei✓e.(aCity So�K -dn Lic# Phone#"a 34- 051 6 <br /> sAel: <br /> GIS Coordinates: X , Y , Township a � Range (p E Section aI <br /> WORK TO BE PERFORMED: <br /> a NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE <br /> 0 WELL # U PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL $ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING MW - 0 HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES n NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:_ <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH_ - 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ( 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 Ordinances, Rules and Regulations, and all applicable California State Laws . <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> TPE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> I 1 .1; R ;� <br />