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04/0]/2004 ll:l0 2094683433 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQuIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br />Application Is hereby made to San Joaquin Counly for a permit to conatruc). andlor instal the work described. This applintilon m made in complance with San <br />Jcaquin County Development T>tie, Cnepter 9.1115.3 and the Standards of San Joaq-jin County Environmental Health Department. <br />�l� ! 1 Assessor's <br />WELL Location1 q�-$ Wi r � r STr�d t _Cross Stmet1,, S ./Q C ty �Ti�� Zip 9-�2 ° Parcel# <br />PROPERTY Owner )cG Pc rk A v Gi1y e+- o rt Zipltl/aZ Phone* Z! Z 2 c <br />C 57 GOntractDr G2 G hui ro+.Mi. ddress�G p� �; 1 G St) _City Gr 4zi,) a py 1C#7�Fthone# -(W 936 2 �p4 <br />Consults nt /Sub Contractar�� 4141, Address3 GJ. ea.r��o 2"%CIry ��.4Lk# Phono# �. 92Ly <br />GIS Coordinates: X —.Y Township Range Section <br />w0 K o B PERF ME <br />EW 16rELL/ BORING (CPT. GEOPROBE, HYDRQ NCH, HAND -AUGER, OTHER') ❑ DESTRUCTION (choose type Ealow) <br />�5OIL BORING # p OVER -BORE. <br />{-WELL ii I PRESSURE GnRO IT <br />Other: Grout Spec fieations. T J I �- �'Atcr c� //5 44- rd! /`� , e <br />COMMENTS: <br />JYPE OF WELL <br />INSTALLATION TYPE <br />xmONrTORING <br />*OLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/ORIVEN <br />O VAPOR <br />0 MUE) ROTARY <br />AJR SPARC= <br />n PUSH POINT <br />Q SOIL BORING <br />13 HAND AUGER <br />p OTHER; <br />p OTHER <br />W> if L <br />-COMMENTS: P90,10 OU /rt® <br />CONSTRUCTIONS ECIFICA7104S <br />DIA OF SOR`cHOLE ULTIPLE CASINGS? p YES X11 WELL CASING CIA. Z hcA <br />CASING THIGKNESSSN-A IYPE OF CASING: j} STEEL PVC p OTHER: <br />DEPTH OF GROUT SEP.- 2 f gREmrn TYPE TO BE ERS HOSE <br />GROUT SEAL PUMPED: 0 Yee VNo (NOTE: MAXI UM REE -FAL 'DEPTH IS 3Q') <br />c;ouT Sat:clFlcaTlorls: �1 �A e6 � � <br />APPROX. BORING DEPTH SS 4"t ,.a$OLTEb TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROP ED,? M3 (if YES, list speJAratlor4 here)' <br />)aO1,.0 6, W- �QPAv'f�__34` <br />Nr)TE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRt_U ITvsreu I IUria, <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord' antes, Rules and Regulations, and all applicable California State Laws. <br />Signed xd/� G r TillelCompany <br />Print Name S c i. h 1- S e► rano t` Dale Y L V <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Gout Inspection 8y <br />Destruction Inspection By <br />COMM ENT5I CONDITIONS <br />ACCOUNTING ONLY: I AID# <br />cerM <br />. <br />sausd ' � ` A a �r , ,•� <br />Inspection By <br />� n <br />/i !'n t r /.tt, , ro Li --A— _ rid <br />II PE CODES I FEE INFO I AMOUNT REMrfTED I CHECK # I RAC,Uyl I DATg r 1 PERMIT/SERVICE REQUEST# j INVOICE <br />soy I g� 610 1 d <br />C-57_ WC= WAIVER^ C-57 Letter of Authod <br />i <br />permit oat menoc _ 25/02 <br />