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WELL PERMIT APPLICATION F,,.:M <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <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 Hellth Division. <br />AssesA ri VA)7T- CiToe�ToAl Zip 7, � Parcel# NQ <br />WELL Location La a rte A-�� Cross Stre..tFiQ _ City S <br />e s y2T A) 'eL �il/�� ;ity J` T�N Zip SZo2Phone#_ <br />PROPERTY Owner i' 1 Ty 5117�L'i2�ti Adores f <br />IM <br />C-57 Contractor (11 00� GJ A� <br />Address P.1), .� �oX 3—City la JS��P Zi __Z/ Lic?# t00% Phone# %a7 ?7Y y <br />4-7"G /iSSo -rE S' Addressfll% /OPJE 84"'1CityrtfoDasroLic# <br />Consultant /Sub Contractor <br />GIS Coordinates: <br />N <br />Township <br />Range <br />WO K TO BE PERFORMED: <br />E`N WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING <br />R,<NELL #-`W"&-L& <br />Grout Specifications:_ <br />'Other: <br />COMMENTS SCC Wq , wy*,pcAQ REV/s6� o� f A/4E�+� <br />TYP OF WELL <br />INSTALLATION TYPE <br />ONITORING <br />OLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />[] OTHER - <br />T <br />Phone# L <br />Section <br />0 DESTRUCTION (choose type beloyr) <br />OVER -BORE <br />PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS i / <br />DIA. OF BOREHOLE y -Zo,, MULTIPLE CASINGS? 0 YES O `NELL CASING DIA.: Z <br />CASING THICKNESS <'CI✓ //p TYPE OF CASING 0 STEEL �VC 0 OTHER: <br />DEPTH OF GROUT SEAL V AA, A�ItLE TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: e(es 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH /FAPQOX 15-125 g c OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_ (if YES, list specifications here): <br />"COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS oOR ENCROACHMENTALL UIRED INSPECTSIONs. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOUR <br />I hereby certify that I have prepared <br />County Ordinances, es and R <br />Signed <br />Print Name <br />-Al C--4 <br />is application and that the work will be done in accordance with San Joaquin <br />tions, and all applicable California State Laws. <br />�� <br />Title/Company ,54.,C,,-�/S% <br />Date <br />DEPARTMENT U5t UNLT <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />t Date Issued IS D ` Area 2 <br />Application Accepted Byl Final Inspection By <br />Grout Inspection By ((,� <br />Date O <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PERMIT/ ES -T"-9 INVOICE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK y RECD BY DATE G` l Z�� <br />_7 S�G I ��.OU <br />9/27/oc <br />C-57_ WC= WAIVER_" C-57 Letter of Authorization to sign permit Encroachment doc <br />