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_Z: ORIGINAL <br />�=" o WELL PERMIT APPLICATION FORM <br />co WELL <br />MITIGATION <br />- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />47`" ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />_304 E. Weber, Third Floor, Stockton, CA., 95202 S.B _ COs <br />C/) (209) 468-3449 <br />r7 <br />.. c <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 o����$$$$an Joaquin County Public Health Services, Environmental Health Division. <br />� � <br />Assessors /�, , <br />WELL Location r � Cross Stree City"" - Zip Parcel# 1.7�, Oki x+11 <br />PROPERTY Owner L f t7 o '5-roe-f���rn 4dress 7 S 00 Ar/Va✓y p� City S? c G(C�h Zip 20 Phone# 3/- `� <br />�rjC7�5F �N✓/e i(cfVjrhG�TgI it S p Z _ �3 -.3540 <br />C-57 Contractor - j ..-dress �h ��" s PlCa,oc.. City w /c _ Zi 9S Lic# 68- 6SPhone# <br />Consultant / Sub Contractor Ca /, G o/ EayTk "Address � � 1�rl-, � �✓e- e- ty Lic# Phone# <br />GIS Coordinates: <br />Y <br />Township <br />Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORING (CPT,GEOPROBE YDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) --� <br />NG # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT-/-, <br />`Other: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD <br />[] AIR SPARGE PUSH POINT <br />Q t> <br />SOIL BORING 0 HAND AUGER <br />BOTHER YwvG 0 OTHER <br />rob <br />'COMMENTS: <br />Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE__ MULTIPLE CASINGS? 0 YES [] NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: _ <br />DEPTH OF GROUT SE. -',L- TREMIE TYPE TO BE USED: 0 AUGERS OSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')�e , <br />GROUT SPECIFICATIONS: MC— <br />APPROX. BORING DEPTH__ 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 IN5Nt1U I IUNJ. <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 andel Regulations, and all applicable California State Laws. <br />Signed /Je K GDas'IV� J49&A t 634 _Title/Company W�a< e <br />Print Name 8/II Cofllrk- {YJ A�o3 <br />DEPARTMENT USE ONLY 9 <br />Date <br />tt <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: —10 - _ <br />Application Accepted By. <br />Grout Inspection By_ <br />Destruction Inspection B <br />/+!1■■■■c■ITC / Pfl\Iflrrinuc <br />Date <br />ERM <br />Issued 7 �'J' i?Y, <br />Final Inspection <br />Area D <br />_.- ngtp� <br />VVI■11■ILI\ I J / VVI\v/ /V. �. <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SE # <br />INVOICE <br />- I 352 <br />2� <br />- J,3-7 <br />C-57 WC -WAIVER_, C-57 Letter of Authorization to sign permit tncro 7� <br />-0- & 418 <br />