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n} — 1, <br /> FEB 1 9 2003 WELL PERMIT APPLICATION FORM SITE <br /> ENVIRUNMENT HEAL44N JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> PERP•11T/SERVICES ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> YYl w, l (209) 468-3449 <br /> Application is hereby made to San Joaquin Ct-REFUNDAgEsu IT RsISSUED <br /> ouury for aperrmito construct and//oinstall the workk described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapte((9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Porta,A V� 6. S�wcLb <br /> WELL Location A1�4<ene to Sf ckt_ Assessor's Street -t'WM Cit 5]ock?at Zip9SZ0't- <br /> Parcel# 137-Zt!,- 17 <br /> PROPERTY Owner<jak1-" 1�2 elapn4l�1c/ Address C,'ry 1ta City-66!kF+ Zip4 ZVL- Phone# <br /> C-57 Contractor CkPlDfa,p (SCO$" O, Address (S3S :W4* " AVCS„ �>n ZI [�'],11-L Lic#1444 PBS <br /> City$5n p Phone# L lOfb-zeD-�QCZZL <br /> Consultant/Sub ContractorGgk., C�oa,,p Scr+We, C.,�. Z16 <br /> ' Address_Iorl2AlhAl CM4r_ QCrk_� City Ic�Kvv / Lic# -'- Phone#%S-L126-Zil <br /> GIS Coordinates:X 3T S-7 dn� ,y\�, b \'1I R W ,Township N Range 66 <br /> Section Ib <br /> WORK TO BE PERFORMED <br /> &NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) H DESTRUCTION(choose type below) <br /> []SOIL BORING# <br /> [I WELL# N W Z 1 HOVER-BORE <br /> 'Other: <br /> COMMENTS. Grout Specifications: H PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 7 <br /> H MONITORING H HOLLOW STEM DIA.OF BOREHOLE LI• MULTIPLE CASINGS?0 YES flNO WELL CASING DIA: Gi1 <br /> 0 EXTRACTION H AIR HAMMER/DRIVEN CASING THICKNESS%L141At t{D TYPE OF CASING: O STEEL W)PVC O OTHER: <br /> 0 VAPOR H MUD ROTARY DEPTH OF GROUT SEAL b-lol TREMIE TYPE TO BE USED: IJAUGERS 0 HOSE <br /> []AIR SPARGE H PUSH POINT GROUT SEAL PUMPED: H Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> U SOIL BORING H HAND AUGER GROUT SPECIFICATIONS: 0�k C91*t b <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH Z S It BOLTED TRAFFIC BOX or H STOVE PIPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED? n9 (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 Ordinances, R s and Reaulations, and all applicable California State Laws. )) <br /> Signed xlr_ 4 f Title/Company PR i ,j 6' ,44aKl kj <br /> Print Name �,,AAarh , ' <br /> Vvl WCL i,/Am <br /> Date ZIl0I�3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /r 1✓ <br /> Application Accepted By A Date Issued '1, ZD <br /> AreaV.T <br /> Grout Inspection By Da Final Inspection By Date-jL/� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> onyx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# IP <br /> ° R20o z a1 sR 3 Z�1�3 <br /> C-57_ WC--WAIVER— C-57 Letter of Auth iz ion o sign permit_Encroachment doc <br />