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WELL PERMIT APPLICATION FORM SiTE <br />!MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />DEC 10 200I - 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />���yl�� (209) 458-3449 <br />� MI ' , - )i NON-REFUNDABLE PERMrf EXPIRES 1 YEAR FROM DATE ISSUED ORIGIN <br />A L <br />Application is hereby made to San Joaquin County for a permit to construct and/cr install the work described. This application is made in compliance with San <br />Joaquin County Development T Itle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />`` I � Assessor's <br />WELL Location I Nc�r P}t y? S-} . CrossStreet i f' City ��C% K oy, Zip S�� Panel# _ <br />r V Put �N Address t' C L <br />CX (T U j! j City C N Zip Phone#(?�1) S -E <br />PROPERTY Owner a V o ll <br />C-57 Contractor Address n,_ r City. 3 Lici#C-��'r73�> Phone# -769 7 /0 <br />//0C.: <br />1 ,t � � v <br />Consultant / Sub Contractor k� Address � 7 S �u W `�t +£ttY �i ti I S L �c# Ud-.�7Phane# % <br />GIS Coordinates: X , Y Township_ Range __ Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING ( CPT. GEOPROBE. HYDROPUNC, , HAND -AUGER, OTHER') [] DESTRUCTION (choose type below) <br />,VOIL BORING # " n ' I] OVERBORE � <br />WELL # a PRESSURE GROUT <br />'Other. _Grout Specifications: — <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l� <br />Q MONITORING 1] HOLLOW STEM DIA. OF BOREHOLE � I MULTIPLE CASINGS? Q YES Q NO WELL CASING 0 Kfi —! . i; <br />Q EXTRACTION I] AIR HAMMER/DRIVEN CASING THICKNESS 7UA1 TYPE OF CASING: 1] STEEL [I PVC p OTHER: \\ <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -P-- ✓1'F111 � TREMIE TYPE TO BE USED: Q AUGERS a HOSE <br />p AIR SPARGE *(PUSH POINT GROUT SEAL PUMPED: [7 Yes ."o (NOTE: MAXIMUM FREE -FALL CEPTH 1S 30') <br />r1j-011- BORING 1] HAND AUGER GROUT SPECIFICATIONS: <br />0 OTHER: _[I OTHER _ APPROX. BORING DEPTH c' !7 BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTCR CASING PROPOSED? (if YES, list specifications here):__l� _ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEN I VtKMI I Z). <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordina9ces, Rules/I ��a>r>,d Regulations, and all applicable California SjjtatteQLa/ws. <br />Signed x �� �V (N` Tide/CompanyS T� <br />Print Name 17 1 �1 1 / t M C' in Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: <br />S� <br />Application Accepted By Date Issued �� G 'tea -- <br />Grout Inspection By Date Y Final Inspection By Date _ <br />Destruction Inspection By Date <br />COMMENTS a r CONDI 1 Ulm <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />1 ieWe?- <br />REC'D BY <br />DATE <br />PERMIT / S UEST # <br />INVOICE <br />a-SR#v <br />n M7/(1(1 <br />ZE <br />�-�' <br />I 6E <-�7 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit C Encroachment— <br />