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WELL PERMIT APPLICATION FORM <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 />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 />r.. Assessor's <br />WELL Location IASLII-1 \AI ox t 2.0aci Cross Stree622(M)()? -CityeekA1SY1 Zip9 51-1 Parcel# <br />PROPERTY Own eNe.X.WEAVIr DAV,C.,-CIINI(Adress YID% sti),>0)( LOCOLA Ci&f1VgaMen Zi`pl :51.3_Phonek(425)Sittl -01(055 <br />C-57 Contractorbff CLV1 \\ 1"Cir,\ Addressq6D rC2.21FALq53 Lick:rid-0 Phon41203PDSRD <br />Consultant I Sub contractoCZ2..ilAbit%).1Addres?V1 Li re ed, ciVdrelardsvait Ph one#P1.1() tab L) <br />GIS Coordinates: X . Y , Township Range Section <br />WORK TO BE PERFOR D: <br />CPT NEW WELL I BORIN C ,NGEOPROBE, HYDROCH, HANIAAUGER, OTHER*) a DESTRUCTION (choose type below) — 1 <br />I SOIL BORING # a OVER-BORE <br />WELL # a PRESSURE GROUT <br />*Other: Grout Specifications: <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING U HOLLOW STEM <br />U EXTRACTION a AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />AIR SPARGE g PUSH POINT <br />V SOIL BORING 0 HAND AUGER <br />U OTHER: a OTHER <br />"COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE V I MULTIPLE CASINGS? D YES *NO WELL CASING DIA. <br />CASING THICKNESS TYPE OF CASING: I] STEEL 1] PVC 0 OTHER: <br />DEPTH OF GROUT SEAL ID TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMU FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ....0•Weldotot PI- <br />APPROX. BORING DEPTH I 4.. a BOL D TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROWL)? ( 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 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 Ordin es, Rules and Regulations, and all applicable California State Laws. <br />mmor 2,etto&In byi3y,n\ntkA. <br />DEPARTMENT USE ONLY <br />c,y a/aZ1.66 <br />2 2- 6 <br />Application Accepted By Date Issued <br />Grout Inspection By Date Final Inspection By <br />Date <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT - a , -.- • --.... INVOICE <br />.. SDI 5513 i 43544o adt 7-(z.bi ..R# 002.00I <br />-WAIVER <br />C-57 Letter of Authorization to sign permit 9/27/00 <br />Signed x <br />Print Name <br />Title/Company <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Destruction Inspection By <br />COMMENTS 1CONDITIONS: <br />7.24-0( 068+ Area <br />Date 7.z..o 2. <br />C-57 WC <br />EEVE89P606 IE:ET 000Z/170/ZT aocru KLAT3 LEt39Vd