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WELL PERMIT APPLICATION FSZIVGEC <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE§Am 1 AJNGT IV ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 9526IVIRONMENT HEALTH <br />(209) 468 -3449 PERMIT/SEIVIRVICESe <br />I <br />ION <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 Joavin County Public Health Services, Environmental Health Division. <br />WELL Location per-5-1-- ait?-(6-tort ..,wof-_ Cross StrektiOn e/(e_.- CitysT,e4Zip4.7.5.2Z5 Parcel# <br />PROPERTY Owner:P(J S'iece__ Address313,,La _C 14147.12F1:,City.S7Ax-0142k Zip."Phone# 4h6? S-3 )7 Co 1 k_ <br />C-57 Contractor 1.442&*1642_ Mai I Addrei&?.....5-.,.:VrAT:54.12a ek City ‘67, Zire_7__*L2Lic -4729)Phonei2ik' 65 <br />Consultant / Sub Contractor -4 -&-16 -/k.' Address e9.Y(51-14:YLL)- a City gre i;AL'ic# Phonbill 'ill:7/2 /X-16 <br />GIS Coordinates: X , Y <br /> <br />, Township Range Section <br /> <br />KTO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />[] SOIL BORING # <br />a WELL # <br />*Other: Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS e 11 <br />DIA. OF BOREHOLE g , 1f0 JIMULTIPLE CASINGS'? <br />n <br />0 NO WELL CASING DIA: '-'` 1 <br />CASING THICKNESS 69- 4> TYPE OF CASING: a STEEL ,a...14c a OTHER: <br />DEPTH OF GROUT SEAL dit4/74; TREMIE TYPE TO BE USED: ItsktJGERS 0 HOSE <br />GROUT SEAL PUMPED: Aves a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 1, Lilys=e--- 7 .Beetha-cH-r-, — <br />APPROX. BORING DEPTH /5t,' Ft------)StOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? A/14 ( if YES, list specifications here): <br />Aie 115- — in 1,(/ ki t,‹..) .,:la4 <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 />Signed x Title/Company <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ,4:03J C.-a (A-M 4ed 06 40 S-iniL. <br />WORK PLAN DATED: c• ::c4-1 wo ,7p--PX ,i wc-c_l_a_ t2//6'io-7 <br />Application Accepted By it,i1 Date Issued 61 , Area <br />Final Inspection By , 1 Date Date <br />Date <br />• kolannIVICri I J / %.•,./IN.../111,•••••••• <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE <br />\--6)/ L. g5 <br />6 9 c)%o /C3/5 /-a-- L /5"th 00.74.47q - <br />- . . . n 1)7 inn <br />e)11— <br />DESTRUCTION (choose type below) <br />a OVER-BORE <br />fl PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />*NITORING >6_:_)LLOW STEM <br />a EXTRACTION 0 AIR HAMMER/DRIVEN <br />VAPOR a MUD ROTARY <br />- a AIR SPARGE U PUSH POINT <br />El SOIL BORING a HAND AUGER <br />fl OTHER: a OTHER <br />*COMMENTS: <br /> <br />(% <br />‘,1 <br />Print Name <br />Grout Inspection By <br />Destruction Inspection By <br />C-57 Letter of Authorization to sign permit croac me C-57 WC -WAIVER