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ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />v _ e SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />3 (209) 468-3449 F E B 2 1 2003 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HE&AhApplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatiorpj iJ��Ii San <br />Joaquin County Devalnnn,Pnr T th- (.h.-fo. 0111 C a = - Standards of San Joaquin County Public Health Services, Envi'ro�Rg'�it�� N�dItM [DIn. <br />!, , // Assessor's <br />WELL Location /`.1..0 N'; .16a4s Street �/`.City �TD� IA°� Zip % ' 2- Parcel# <br />�(Z-6'4V,77­00653 <br />�t <br />PROPERTY Owner �7Y o 04 S7Zt�7V 1V Address `1rZj• •'�G/ l!a 0 S%City Sj %1f�i� Zip S�Z� Phone# �zx 5 Sri% 8��? <br />/ �.~, rtc! f5"T 4 <br />C-57 ContractorL,•i /f"J0� iCtiNl� Address Z O�I�G G�2 City l��/t1h'/+'}' ZipfY7yLLic# ��JS/0 Phone# <br />' ,,,,..,,,,,,,,, <br />Consultant/ Sub Contractor �L`C�/� �'�'+�/�"4ddress�..ftV7 114e 0W QV ��L' City Phone# 0VC0 <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County OrdinancesjR <br />LAOS and Regulations, and all applicable California State Laws. <br />J �' _ f <br />Signed x Title/Company !-���' �✓ S <br />Print Name e5�71 � IVT r'J 5 Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />.S� ��6 o <br />Application Accepted By Date Issued 6 ^ z(.- o 3 Area <br />Grout Inspection By Date Final Inspection By. <br />M21111 V.710", 1ate� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />Gera <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT /SERVICE REQUEST # <br />GIS Coordinates: X <br />, Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER* [] DESTRUCTION (choose type below) <br />[] SOIL BORING # <br />VER -BORE <br />''WELL # <br />[] PR SURE GROUT <br />'Other: <br />Grout Specifications: <br />COMMENTS: <br />/U, 2 /!57 Al. 3 D <br />TYPE OF WELL <br />INSTALLATION TYP <br />RUCTON SPIFICATIONS <br />!' <br />MONITORING <br />HOLLOW STEM <br />DIA. OF BOREHOLE M�LTIPLE CASINGS? [] Y L CASING DIA: <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />CASING THICKNESS BN' yb 6TYPE OF CASING: [] STEEL )"PVC [] OTHER: <br />[] VAPOR <br />[] MUD ROTARY <br />DEPTH OF GROUT SEAL 6S TREMIE TYPE TO BE USED: [] AUGERS )(HOSE <br />[] AIR SPARGE <br />[] PUSH POINT <br />GROUT SEAL PUMPED: K1'es I]]/No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />z <br />[] SOIL BORING <br />[] HAND AUGER <br />GROUT SPECIFICATIONS: /�G°.�T e�qCEN%_ <br />` <br />[] OTHER: <br />[] OTHER <br />APPROX. BORING DEPTH �[� )t$OLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? if YES, list specifications here): <br />d <br />`COMMENTS: <br />NOTE: <br />OFFSITE BORINGS <br />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 OrdinancesjR <br />LAOS and Regulations, and all applicable California State Laws. <br />J �' _ f <br />Signed x Title/Company !-���' �✓ S <br />Print Name e5�71 � IVT r'J 5 Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />.S� ��6 o <br />Application Accepted By Date Issued 6 ^ z(.- o 3 Area <br />Grout Inspection By Date Final Inspection By. <br />M21111 V.710", 1ate� <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />Gera <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT /SERVICE REQUEST # <br />INVOICE <br />55o <br />C•57 V WC= WAIVER C-57 Letter of Authorization to sign permit Encroachment coc ✓ 9/27/00 <br />6(P 3R <br />/2w 0 03-�w <br />