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WELL PERMIT APPLICATION F8IIRM <br />c\o SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />S <br /> <br /> CL $1-\) ,-\\,ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />O'S\• 53 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />0 \ Q 9,0 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 Health Division. <br />Assessor's <br />WELL Location; lo E. 1.00A-rvire. si-, Cross Street Alla iii 517 City (1/10vi+1°Cal Zip \--33(,„ Parcel# <br />PROPERTY Owner C Ay CP 114 a 114.--e CM Address )(X) 1 1.A.). Cevliti `3/: CityAlarri-eC a Zip 95376Phone# <br />C-57 Contractor (til ii-cfne/i Orli' iiy A ddress cc360 c LA.)*Prue City <br />r 0 <br />0 Zip (3_&Lic# kDa7Phone# (9/6 ) 7 - i/a0 1 1 1 <br />Consultant / Sub Contractor-4API cerP C'eoEtwirovYktaddress q3-1 51/64•1241 City5totM/lLic# 60,17 Phone# i-767 -/dd 6 <br />GIS Coordinates: X , Y <br /> <br />, Township <br /> <br />Range Section <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED: <br />ANEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />Q SOIL BORING # <br />WELL # NA (4.4 — <br />*Other: <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />U OVER-BORE <br />[I PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />,MONITORING )(HOLLOW STEM <br />I] EXTRACTION AIR HAMMER/DRIVEN <br />fl VAPOR fl MUD ROTARY <br />0 AIR SPARGE fl PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />OTHER: fl OTHER <br />CONSTRUCTION SPECIFICATIONS i i <br />DIA. OF BOREHOLE ,R 1' MULTIPLE CASINGS? a YES ,tk<0 WELL CASING DIA: d- <br />CASING THICKNESS.Sdnelute 'f7 TYPE OF CASING: 0 STEEL 44•0\/C 0 OTHER: <br />DEPTH OF GROUT SEAL 5 ' TREMIE TYPE TO BE USED: ArA U G E R S 0 HOSE <br />GROUT SEAL PUMPED: a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 10') <br />GROUT SPECIFICATIONS: ,,41/0n; 041 i-fx, 4„ qq/6 5qc4 For:lic.,,Ac.,/ <br />APPROX. BORING DEPTH 30 NI3OLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? No (if YES, list specifications here): <br />*COMMENTS: <br /> <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />6e())./ 51-- <br />Date 3 0/ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />• <br />t rt./.A-A-c-ct, <br /> <br />Date Issued 31 0_ ) tt Area <br />Date ‘-V5-fc: Final Inspection B (A. <br />vir,v_I <br />Date 45/C7( <br /> <br />\ <br /> <br />Date <br /> <br />-- ...... —•-•—• <br />ACCOUNTING ONLY: ONLY: AID# FAC.# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE U INVOICE <br />, <br />3 5-0 I li %et . o o I 4 cis--i-- tikk 3 3 ° I SR# On 2,S (7 Cci <br />rt I-3- I inn <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign per ncroac m <br /> <br />> <br /> <br />Signed x <br />Print Name (22P; an All 11 <br />DEPARTMENT USE ONLY <br />Title/Company