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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 952020 R1 <br />-GINAL <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 <br />Health Division. <br />WELL Location 1jn1_ % I�FST ��M�lU i ST Cross Street - - 5 City 51-cc-e-Ty"'J Z. ;ZC 5 Parcel# )"] �7 <br />PROPERTYOwner ATLrA ►jnC_�tGt1T�1E1-b Address F� BCX Sl`+�Z Q'� CitygL'Gnc Qcr+ Zip i0(DZz Phone# 9ZS "-$E91 <br />�7�" tyQJ}(r��"'W—Zip9574Z Lic#5S4-'7q7Pnone# tv 3 -861 <br />C-57 Contractor Val k AZrv1►�T l'fGt►ruC�ddress 3 �TZ6ERrtL1� pcQ- Ci <br />ynQER�1 Ci , , ojD3'ALic# MA Phone# I- v <br />Consultant/ Sub Contractor Se`CGl� Zn�er.0 noAj Address 31z-1.� U <br />ty � — <br />GIS Coordinates: X <br />Y <br />Township <br />Range <br />Section <br />WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br />0NEW WELL /BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") CJ 0 OVER -BORE <br />0 SOIL BORING # L, S0.- g-'�� <br />PRESSURE GROUT <br />[]WELL # , 0'Other. x Grout Specifications: �r! Tal E ` tP <br />17 IL Zn W� (Fo�IOu Sw� %iV ciPr: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[] MONITORING <br />a HOLLOW STEM <br />[] EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />[] AIR SPARGE 0 PUSH POINT <br />&SOIL BORING [] HAND AUGER <br />Q OTHER:—0 OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE_ MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: K;A <br />CASING THICKNESS N A TYPE OF CASING: [] STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL ''L-�) TREMIE TYPE TO BE USED: 0 AUGERS 0HOSE <br />GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Tr&m%E P%PC C-Ium 13-''tor✓i ro Tp() <br />APPROX. BORING DEPTH ZO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Iv: ( if YES, list specifications here): <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 Or inane s, u es and Regulations, and all applicable California State Laws. <br />Title/Company SEGO (L t.,A T'E 17 n1 nb - pro. �Z'f 6t oL at <br />Signed x <br />_ Date S I -n /o7 <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: <br />Application Accepted By Date Issued_? Q� <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />)13 - <br />PE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # <br />C-57_. WC_ -WAIVER C-57 Letter of Authorization to Sign permit_L_ Encroachment doe_ <br />INVOICE <br />9/27/00 <br />