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WELL ERMIT.APPLICATION F RM SITE <br /> - <br /> ' 'j7"' `­ MI G—ATION <br /> SAN JOAQUIN COUNTY f.#,'.It�fil IPI" I_ f�� IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EH, <br /> 304 E. Weber, Third Floor, Stockton, CA.,Eff 17 PM 2: 12 <br /> (209) 468-3449 ��tt <br /> NON-REFUNDABLE PERMIT EXPIRES'I 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 Title,Chapter 9-4115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> `�71 I' p Assessor's <br /> WELL Location $�� N. --�rw�iL__�T (�. 1' ^Cross Street 1CtV' o City S��h Zip Isa`LZParcel# 0157-30-ti <br /> PROPERTY Owner �Y �+Yl41,HU)t rk r ft �ddress 30 S. SUM Si_- City S n Zip?sZO3 Phone# Z4W -CO <br /> C-57 Contractor \J t;W (�kWt-4 Address 160 .P-k %rtltCityTS-Ie-4t_� Zip SIA(Lic#7200 Phone#gq,.777-L100 <br /> Consults Sub Contractor �'d -OLCO A+ Y� tddress Rt' � �E+e�t" City �0i•a� Lic# Phone#ZaF�3Qeg <br /> GIS Coordinates:X 'Y Township Range -7 Section ISE <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# Md+v 10- Mw►t� �Lw t�, NUW 13G,VEV✓1 a PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> — - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPE`CIFICATIO Sbr�vC p jff� k <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE MWS LTIP E I�uINJ0 YES YN0 WELL CAG A !A'W13j1lC'tF� <br /> 0 EXTRACTION 0 AIR HAMMERlDRIVE CASING THICKNESS C14 SID 5Cr Yh F r-�A�11yi3 STEEL )(PVC 0 OTHER: <br /> VAPORVEU�l MUD ROTARY f"lW I3G EPTH OF GROUT SEAL�N SD�+�' 7fRENIIEr"TYPE TO BE USED: AUGERSH05E <br /> 0 AIR SPARGE 0 PUSH PDI GROUT SEAL PUMPED: Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3(}'). <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ' Mws <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH M S'tiI BOL�AFFIC BOX or 'STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? if YES,list specifications here): <br /> *COMMENTS: MWIGH 2- %Saki be 2-1-c1s kc,�itf caaC-r,t ftp 1- ; Vt;w l w7icL J-1 y�`,, d�a�*e4y� 40_&59 <br /> fAw vs L3 <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company 2f-, cals- (( 6w4 <br /> Sr <br />,L Print Name �'e _ _, ---- -:Date- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Jr. Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> estruction Inspection By Date 17 <br /> COMMENTS/CONDITIONS: ! ar / C Spm <br /> ACCOUNTING ONLY: AID# M V 01 y 5 V Fr �.t t-V 9 20e) / <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATEPERMIT I SERVICE REQUEST# INVOICE <br /> VhM q <br /> C-57 WC -WAIVER___ C-57 Letter of Autho Si6n permit Encroachment doc 1/25/02 <br />