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SAN JOAQUIN COUNTY on SITE <br /> c� EN-�rONMENTAL HEALTH DEP R' GATION <br /> ` UNIT IV <br /> 304 East Weber Avenue, 3"I Floor, Stockton,CA 95202-2708 <br /> (209)468-3449 •Fax:(209)468-3433• Web:www.co.san joaquin.ca.is i ; <br /> �P _ u <br /> '4C7FORl� <br /> WELL PERMIT APPLICATION FORM AUC y S 2005 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVI iapp�with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install Ire work described. This appt &)rTq"j!I l-' <br /> Joaquin County Development Title,Chapter 31115.3 and the Standards of San Joaquin County Environmental Health ODlee �J;S LI 1 <br /> WELL Lowtionl`1-)Sb FLi � Cross Street I A CitySTDL� '�zp7z)S Parcel# 163-14o-yF <br /> PROPERTY Owner S'MS 6 121121(ze,��Address/'1-150 F11A14 q� Cipty�$;�ZC'�11`� Zi{{31SZISPhane#2 <br /> C57 Contractor Y Q AO thra. c S01,31 Address3li -Z-S S o. (n�fFnfl Ciry ' "1--LIA- uar 4 r u I-t8 Pnone#5sa-�`1 i-r Y o r <br /> Consultant/Sub Cntrl)H.VO(2 f-F45Cfkkcnr( addressCiry w(MOlM9 Lic# Phone#53D-L(o( -0164 <br /> GIS Coordinates:X ,Y ,Township-i 1 CS Range IC fz Section 2 2!- <br /> WORK <br /> WORK TO BE PERFORMED: <br /> ' .NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) B DESTRUCTION(choose type below) <br /> / B SOIL BORING# B OVER-BORE-DIAMETER <br /> B WELL# B PRESSURE GROUT <br /> U•Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q 11 <br /> MONITORING B HOLLOW STEM DIA.OF BOREHOLE j0L_MULTIPLE CASINGS?B YES I NO WELL CASING DIA: <br /> '`EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS��" TYPE OF CASING: U STEEL 1PVC B OTHER: <br /> B VAPOR ROTARY DEPTH OF GROUT SEAL 171 TREMIE TYPE TO BE USED: B AUGERS WHOSE <br /> 0 AIR SPARGE B PUSH POINT GROUT SEAL PUMPED: WYes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING B HAND AUGER GROUT SPECIFICATIONS: tI SReX era-/ ALU I Ly_ <br /> B OTHER: fl OTHER APPROX BORING DEPTH (O5 B BOLTED TRAFFIC BOX or ISTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? _('rf YES,list specifications he V _ <br /> *COMMENTS: <br /> I�0 ��a—5 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEN -R 7'8. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INN P EE , P <br /> OQ O�0 <br /> I hereby certify that I have prepared this application and that the work will be done In accordance w' quin <br /> County nd Regulations, and all applicable California State Laws. <br /> Signed x Title/Company YUS, kr A <br /> Print Name 0.�yvJ A `ir Q-A 0(j�=4 Date FIyiftjs <br /> DEPARTMENT USE ORLY \ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 E• Y/ST Z9�65x I✓ <br /> WORK PLAN DATED: F <br /> Application Accepted By Date Issued Area rJ r+ <br /> Grout Inspection By Date Final Inspection By Date + -0 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED OIfECK-#' RECD BY DAV PERMIT/SERVICE REQUEST# INVOICE <br /> ?st E SR (xs rf 3 SRV 3 <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth4o)7 ttfi Tgn permit_Encroachment doc_ <br /> RECEIVED <br /> FRI)X002-001 AUG 2 3 2005 WEI. PERMrrsrrE <br /> SAN JOAQUIN COUNTY <br />