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FILF Copt <br /> rqurh 'SOL SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEP AR TIGATION <br /> 304 East Weber Avenue, 3d Floor, Swckton,CA 95202-_ � � l/%iris n IV <br /> (209)468-3449•Far:(209)468-3433• Web:w .co.san joaquin.ca.us/eh U I_L� <br /> F a� <br /> WELL PERMIT APPLICATION FORM JUN 1 6 2004F�`'1/' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'RONPVI(_IV I H . <br /> Appficallm is hereby made to San Joaquin County toy a pemrt to construct and/or install the work de abed. Th9arm with San <br /> Joaquin County Development Tine,Chapter 9.1115.3 and the Standards of San Joaquin Courrty F11Nranmantal Healt'=W41 C, rhr>re i S <br /> r1 O ,s Cross Street • 'S ISy City ! .,�-Y Zip 15�/ arcew A�esson loo -02 <br /> WELL Location A� 1 �J"��ci f'�'ecSo� <br /> PROPERTYOwnerU'I��tl IJT >t-LL,_Address�`l� GtyI'�"a�. .. ZipCL�p��Ct Ph1r114 � <br /> C-6!contractor Gfc�� Jc,l\i'lQ Address '?rO /IMft !Rd Cmc�f 4T-0♦�AP} L,41 `-^ Pt,,,na 12.r-�3•SdW <br /> J ♦j14 <br /> Coneultant1 Sub Cntr C7 1 o4'v r C-� 5e:J-.ieSddrasa kt�Y o (�1'l G iq�Pi.+'Oiry�F IC< c.tled Phone# �G 6C= <br /> GIS Coorcllnates:X 3 D! ,. d i 9 V ,Y (,`l 3�✓ ,.Township 5 Range -4 E, Section 3 <br /> WORK TO BE PERFORMED; <br /> ;NEW WELL 1 BORING(CPT,GEOPRCBE.HYDROPUNCH,HAND-AUGER.OTHER•) D DESTRUCTION(choose type below) <br /> SOIL BORING# I C3 0 OVER-BORE-DIAMETER <br /> - <br /> a WELL# 0 PRESSURE GROUT <br /> 0.0thar. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> () MONITORING a HOLLOW STEM DLA.OF BOREHOLE y�MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASWG THICKNESS TYPE OF CASING: G STEEL G PVC 0 OTHER: <br /> a VAPOR I]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I]AUG2RS a HOSE <br /> Q AIR 5PARGE %PUSH POINT G Ia: I]Yes tl INI��o (NO EE-FALL DEPTH IS 30') <br /> Ac$OIL BORING QHAND AUGER GROUT SPECIFIC <br /> rJ�CtT �rr-an� � <br /> p OTHER: n OTHER PROX.BORING DEFY g BOLTED cU TRAFFIC BOX or 0 STOVE PIPE <br /> �CONDVCTOR NG PROPOSED? it YES.tis eafi ham)- <br /> 'COMMENTS: W D <br /> p �1lYl✓G TE <br /> NOTE!: OFFSITE BORINGS REQUIRE ACCESS OR ENCROA HMEN PERMITS. <br /> CALL THE UNIT N 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, le n one, and all applicable California State Laws. <br /> Signed z Tltle/ComPaM �L7j�/R��IA//E/}��L•I - °-" <br /> PBnt Name ` <br /> Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2505 S . -Flus <br /> WORK PLAN DATED: �'IS •O <br /> Appliratlon Accepted By Date Issued �� v Area <br /> Grout Inspection By F}nal Inspec0on BY Date <br /> Destruction Insoecrion By Date <br /> COMMENTS I CONDRIONS: <br /> ACCOUNTING ONLY: Alpe FAC#. <br /> PE CODES FEE INFO AMOUNT REMTTED CHECK# REDID BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �oS 30((533 Cn 16-l6- SR-0Cp38 9 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign pertnit Encroachment dx <br /> WEI1 PER7.tIT SITE <br /> EHI7 29-07-00I <br /> &772003 <br /> -T Unr <br />