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4'0'� ".&*, FILE COPY <br /> WELL PERMIT APPLICATION FORM �Tf-,, <br /> SAN JOAQUIN COUNTY 16#T164, ,; <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) r ! <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �YTO 2003 <br /> (209) 468-3449 <br /> EfJVIRE�idr�1�iiT f-c�iLl�! <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ade P�RTd9IT1ER`a Iia <br /> fi an <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mm comp lance wi <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location I t3fr 6 Hkil -9-7 ►J Crass Street 64(?_c,r- City D>i __Parcel# b<,-5 - l,(,0-0-3 <br /> PROPERTY _ <br /> Owner T ?1 Address t��`��e ki.1`( 15f nt City (+oS>t Zip Phone*__l g 93 I fe�p <br /> C-57 Contractor GfLi�_67G W 5 r V Address qS'D Ho{g &QA)1:7) CityAM 92tmM Zip 9_NS5 Lic# c7�Phone#�2s3 13 SrOO <br /> Consultant I Sulo Cntr &LOv{L4 ddress Z76) ?2?oSP>_eT PARK City&+C� # Phone# sir; yyq p!Z 3 <br /> GIS Coordinates:X 'Y Township_ro Range-7 I— Section I <br /> WORK TO BE PERFORMED: <br /> prNEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> D SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> W`Other _ GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AfOrJki- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 130 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOST= <br /> 0 AIR SPARGE/OZONEPUSH POINT(GP or CPT)GROUT SEAL PUMPED: gYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH [3 f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDDrs (if YES,list specifications in comment section) <br /> COMMENTS: 3E_ (:2 ; f7 &-rTgA �+�++� OE C-rZE <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Or ' ances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company S4„__S fT7S T/aa&.fnf Asp C' . y( � - <br /> Print Name Date I1 ('0-5 <br /> DEPARTMENT USE ONLY <br /> WQC� - 447'SITE MAP IN UNIT IV FILE,ADDRESS: 6 �' / N�''t e <br /> WORK PLAN DATED: 79— <br /> Application Accepted By Date Issued °' I Area 6 <br /> ex- <br /> 11 <br /> Grout Inspection By Date Final Inspection By <br /> Destruction <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDS FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 1 45E) 12Z47 G� :5-TA 00�)&S (P <br /> C-57 WC, WAIVER C-57 Letter of Authorization to sign permit_Encroac t doc_ 9/30/02 <br /> ��— <br />