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07/19/2002 08: 18 2094683433 r=Ir n rLuur< <br /> WELL. PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY - V D <br /> �7 �1� <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) U1 <br /> _ I �� ���� <br /> 304 E_ Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT WIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Compllanee with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> ^� D1,� � Assessors �� <br /> WELL Locatlon ��ir1 I+/� /i � �Ir Cross Street City��rxtLtr�� Zip Parcel# 1 F�I–- _o–b <br /> PROPERTY Owner Fn},�I1N �tV_p�sn�LL':- Address P•0-�a�xut�6� City h.:zz� Zip'C12t�7Phone# s f5i14 2355 <br /> C-57 Contractor ICI Y Address 2' I` IG T fit- _City Phoned <br /> Consultant/Sub Contractor _Address �-City Phone#�q�i l- +�GLidt 1Ie� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORM D: <br /> NEW WELL KBOR.I (CPT,GEOPROBE; ROPUNC -,HAND-AUGER.OTHER`) p DESTRUCTION(choose type below) <br /> 1]SOIL BORING# p OVER-BORE <br /> O'NELLt_ a PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: NF–?t, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING it HOLLOW STEM DIA.OF BOREHOLE_j,-L_' MULTIPLE CASINGS?13 YES 6NO WELL CASING DIA:Ltf <br /> n EXTPACTION n AIR HAMMER/DRIVEN CASING THICKNESS Lrt TYPE OF CASING: []STEEL [IPVC []OTHER: <br /> P VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: '0 AUGERS [HOSE <br /> 11 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11-S IL BORING n HAND AUGER GROUT SPECIFICATIONS: (sirs"o'JIz- <br /> n OTHER: e0THERSE firs" <br /> e:1fV0 " APPROX.BORING DEFTH St7�—0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? K9 (if YES,list specifications here): <br /> 'COMMENTS: �1u0SuQGf4 1)r- �zy,vC�cs ;N�Oj <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> (-ALL TNF I.INIT IV INSPFCT0R 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Countv Qrdinane s, R es and Regulations, and all applicable California State Laws. <br /> Signed x . ' Title/Company i_,_ �c_� _Ll--,c I�L"_ Ax-s- <br /> nn <br /> Print Name L �c� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Dete Issued 1<< bL AreaCtlg-u'a C/7 <br /> Grout Inspection By Date Z Final Inspection Sy Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# Eery <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> — '_ rt c stxtt <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />