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00,4-91 4 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OCT PhTj%�TION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)ENVIRON JENT HEALTH <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 PERNT/SERVICES <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 Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessors / <br /> WELLLocation Soo E' LoLOre Al F-, Cross Street H6trlah Rrl City LA'/'�7r.j�2 Zip9 30 Parcel# /qg-/jo-vb <br /> PROPERTYOwner L,O( CrIaJJ X,7e-, Address B/l knrJl.r� 13-),799 City / e/echo ZIp_t 0?Phone# 2j_:.gr&-1I` <br /> C-57 Contractor V+W Address_ Jrfcr City-EJ/0'7xK Zips &%/Lic#7 o' Phone# `/6-777-y/oo <br /> /aEr.n�K we�rCJ�-c Le <br /> Consultant/Sub Contractor Cion w1 6 r1b %e.,4, Addressd., 7r-c L City Sroc'<Ar .ic# Phone#ao'7-/V3'/-aS-18 <br /> GIS Coordinates:X ,Y .Township S Range Section / <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) B DESTRUCTION(choose type below) <br /> B SOIL BORING# B OVER-BORE <br /> jjW ELL# B PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r MONITORING HOLLOW STEM DIA.OF BOREHOLE P_ " MULTIPLE CASINGS?B YES J'NO WELL CASING DIA:. <br /> a EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS Sc No TYPEOFCASING: BSTEEL XPVC BOTHER: <br /> - <br /> a VAPOR B MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 'AUGERS B HOSE <br /> B AIR SPARGE B PUSH POINT GROUT SEAL PUMPED: B Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING B HAND AUGER GROUT SPECIFICATIONS: llle,,.{- Cf/yJGr� <br /> B OTHER: []OTHER APPROX.BORING DEPTH o2 v/ B BOLTED TRAFFIC BOX or ,rSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /Uo (if YES,list specifications here): <br /> 'COMMENTS: <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 OrdiinnaaJ/"es, Rules and Regulations, and all applicable California State Laws. <br /> Signed J �l moi/ - Title/Company JYA 4 Geo/arrlJ tl6�z'!o, 5-& >Ar ie-..�_.wloa:e��c <br /> Print Name � C�' H f'`/'�W e- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted B P.�il� Date Issued WaZ 6( Area <br /> e,G(.G. Date Final Inspection By Date <br /> Grout Inspection By - <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 77 7 <br /> 9/27/00 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br />