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o IPA✓ - (-ell- q <br /> WELLUtRMIT APPLICATION FORM SITE <br /> lNECE " E D SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> MAY 0 7 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> 666 Lo. WA:-Ak�prVd_ Ll.ucouJ s'Tor�ycTw1 gSZa3 Assessors <br /> WELL Location Cross Street City Zip Parcel#I37^ 590-OZ- <br /> ML <br /> OZ$2 z_ L�asr <br /> PROPERTY Owner S'1'oG41C ».J t'LOl Address Z We9 ex Atiz- CityIpcl5'Z'Phone#CZ'093 937-8'SII <br /> C-57 Contractor Address 3 g J Z 0f LQO (kkZi° p �Lic# 17 <br /> "(JPhone# <br /> Consultant/Sub ContractorSEc�'_ ---Address:&bl'? "S RLOpo Cltydew.As A- Lic# Phone#C9r,0R61-cyOJ <br /> GIS Coordinates:X ,Y ,Township Range 6 Section 1 0 <br /> WORK TO BE PERFORMED: <br /> a NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> gSOIL BORING# S6--�2 a OVER-BORE <br /> a WELL# 0 PRESSURE GROUT <br /> -Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING o HOLLOW STEM DIA.OF BOREHOLE 9-" MULTIPLE CASINGS?a YES AND WELL CASING DIA: <br /> II EXTRACTION `XAIR HAMMERIDRIVEN CASING THICKNESS fir' TYPE OF CASING: U STEEL O PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS IZHOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: )@ Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> fQ SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: IUt'-Rr Caw -;�T <br /> p OTHER: n OTHER APPROX.BORING DEPTH �7 d r p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 'U L> (If YES,list specifications here): <br /> *COMMENTS: <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 1 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 x Ti / w— Title/Company PN-3C� �e opo y.ST J SE�o.L <br /> Print Name ^Tti'I'b-`^� `/_ PAr�1 Data A-? ISg'Taa'1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /rf <br /> Application Accepted By. l- Date Issued AV C[ rea <br /> Grout Inspection ByDate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CON DRIONS: <br /> ACCOUNTING ONLY: AID# <br /> ce�u <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REOUEST# INVOICE <br /> �" o SR# 3 `130 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authoriz ion sign permit_Encroachment doc_ 9/27/00 <br />