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• MAY 1 4 HLE COPY <br /> WELL PERMIT APPLICATION FORM �= 'ItITE <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 W" C <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �RP/b c <br /> ` 1-(�rl <br /> Applic-afion is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance v if;Sa <br /> Joaqu in County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> /� /n., O Cross Street City Assessors <br /> WELL Location �tp�A��/���� '^�'� r0.C ZPq�7 Parcel# <br /> PROPERTY ower r 1�IJ��T Address-4 11 city Zip Phone# <br /> C-57contractwlr)�cl I z'1-,r � 3ao2`l f=�erald sEl� CtyFarhnCcr `Tip`I5�`L2udF55�?1,-hone#C`IUa� X-7.17 <br /> y —Addresseves 75 3 - <br /> consuRant/Sub Contmctor tr6w� ..� r-21�uel� dress <br /> GIS <br /> !L CiviG1)r aty �1 �- List Phone#� }q. ? <br /> GIS Coordinates:X ,Y .Township—15—Range S F Sectio'--3 <br /> WORK TO BE PERFORMED: STRUC ch se type below <br /> �NEW W ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 1 1 OV R-BORE ) <br /> (1 SOIL BORING# <br /> 1]WELL# t ESSURE GROU <br /> 'Other. e. ie�iOh o-F ell T' - II _Grout Specifications:.- <br /> COMMENTS:- <br /> pecifications:COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> li MONITORING U HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?U YES UNG W ELLCASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [1 STEEL I]PVC [IOTHER: <br /> 11 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 1]AUGERS U HO: <br /> p AIR sPARGE p PUSH POINT GROUT SEAL PUMPED: U Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3 <br /> Q SOIL BORING ()HAND AUGER GROUT SPECIFICATIONS: <br /> U OTHER ❑OTHER APPROX.BORING DEPTH U 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 /> Signedx n __ TitlefCompany <br /> n O <br /> Data �1U A'U1 <br /> Print Name <br /> DEPA'R/TM'E/NT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ?S <br /> WORK PLAN DATED: Z D GT zooms / n <br /> Application Accepted By - Date Issued (� ' —AreaV��� <br /> Grout Inspection By DateFinat Inspection B Dat [ <br /> Destruction Inspection By Date Zoo I <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT/SERVICE REQUEST# INVOICI <br /> 29. 3iyoi Z63r�8 <br /> o <br /> .. ._ ..,.r ', - r Z� 1 to Sinn nPrmlt Encroachment doc 9/2 <br />