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RD ECENED WELL PERMIT APPLICATION FORM SITE <br /> FEB 19 2004 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> uNIT Iv <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> pF'=sMIT/SERVICES (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 /> Assessor's <br /> WELL Location 500 EhST Lows Au"L46 Cross Street 13I 7-Zl 3E ST.city L.A-rn 120 V Zip 9SM6 Parcel# <br /> PROPERTY OwnerfAWipirairw ,Vokrd AMgF 4 Address BNM4015W- P-0&D�L 799 City,%at6Dt1ADR Zip-934,97 Phone# <br /> C-57 Contractor yb fZ 1 u1 A! ddress pD jaD y it/,& City1S1.6To a 1 Zip 95 ,41 Lic#72696Phone#�77-`/lao <br /> Consultant/Sub Contractor L'-�A.IZW-C—.4g tl��ul Address /99 �d4n1K 1��ctrl, itySiZx/Crna� Lic# Phone# 234-DSI X <br /> GIS Coordinates:X Y Township ( l 5 Range 1p Section -35 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER`) Z VtESTRUCTION(choose type below) <br /> 1]SOIL BORING# c 0 OV R-BORE <br /> 1]WELL# Kill ) UJ Z RESSURE GROUT <br /> r-pw <br /> 'Other: Grout Specifications: <br /> COMMENTS: TWoox)lTOAx1AAey W6L-L-15 'Tb a& .1-)&sTAeay&z 47- ldo✓b .egrg-ZA; xlrD 51Z-6 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM J(-DIA.OF BOREHOLE MULTIPLE CASINGS? 0 YES )'NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL eV -Zo A TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ,` Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: e- -5 7/7y 9L-- .T&,nlS1WW <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �^ CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS�FI"7-)W OT Z 1NGu11Tl�.Ly1An t.t eu-.s 7D <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 Ordina es, Rules and g ulations, and all applicable California State Laws. �r <br /> Signed x Title/Company <br /> 4-1 <br /> Print Name _ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ( 30 I S-5 d <br /> Application Accepted By Date Issued <br /> LI;� _ Area 1 Y v <br /> Grout Inspection By Date Final Inspection By Date� <br /> Destruction Inspection ByDate,3 V6 <br /> COMMENTS/CONDITIONS: -�� <br /> i <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMrr/SERVICE REQUEST# INVOICE <br /> (0 4 (00 (0 SR9 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />