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WELL rERMIT APPLICATION FG,,NI SITE <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 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County fcr 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 />Assessor's <br />WELL Location 2804 E. F( -e Mort+ S1 S-rD4 pGross Street 'F�i Intl "i City Zip Parcei# 44 <br />PROPERTY Owner Vtr,Lo Address Z'604 6. rre-y'0A+ St. City. S4`0cL;Mj1 Zip Phone# �1((-QZ33 <br />C-57 Contractor ►'1NQs <br />sc� E;✓I JI /o&Vedfn I Address 399 5 eri IS P�ac c. City_ �ip Z 2-.Lic#�g38GS Phone# 772-- 35`70 <br />Consultant/Sub Contractor A-rC. A5SOL JAc-, Address /117 Lou PA)w #R City_ffoc sto Lic# Phone# 577-ZZ'2-I <br />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED, <br />NEW WELL / BORING CPT, EOPROBE, HYDROPUNCH <br />SOIL BORING # Z <br />0 WELL # <br />'Other: <br />rnMMPNTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />'COMMENTS <br />HAND -AUGER, OTHER-) <br />Grout Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />0 DESTRUCTION (choose type beIV) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />DIA. OF BOREHOLE I.5 11 MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA:&)Iq- <br />CASING THICKNESS N Pt TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL ';4. `l0 TREMIE TYPE TO BE USED: 0 AUGERS kHOSE <br />GROUT SEAL PUMPED: AYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: IJLO. -k Cc w.L-�n �SUntnw C� roo^Y <br />APPROX. BORING DEPTH ti `(0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( 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 IN51'tc: I IUNZ). <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� �+ X Title/CompanyaTC- 4-5500— <br />(J Date <br />Print Name �2.,r..`^ Y\`�. I-�-n nn.S -- <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: `6 ol <br />Date Issued 0/ Area <br />Application Accepted 6y Z 1 <br />Grout Inspection By I h nAA.00_ Date Finai Inspection 6y TTT Date 2 O <br />Destruction Inspection By Date <br />­AAXAV.MT0 / f'f%k1r%1T1n K1C- <br />1iV111111L1':Vl <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />�So ( <br />-4 100 <br />1 S 31 <br />W( <br />Z- o <br />goo <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc - 9/27 <br />