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o C (� e�V E P WELL PERMIT APPLICATION FORM <br />ApR 0 2 2004 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />�jyp,' ivl HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERR <br />ENAIT/SERVICES <br />pE, ,,. (209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />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 />C�y7 i ,, _ I' Assessors <br />WELL Location ^-G- �I �Cr4�'� 51� _-+Cross Street ll+�. City T"�k Zip ��04 Parcel# 1Z%`QED — (� <br />44 <br />PROPERTY Owner 1c�3CO �O'loco Pti%�/�� Address )lIite I�+(�c�/LY�;rEL-)� City; ,ry 4�L+ Ziper r,�( Phone# r /�sr <br />C-57 Contractor �QV�nLh� Snn i C Address Z20 N 65� 5j City` /' Zip�� Lic# �.t���3yPhone# 1 30 tc�cJ'ZyZ� <br />� (�T.aL,' k 'acs i7 K e-� Ci L-� �"`�`Lc# Phone# <br />Consultant/ Sub Contractor <br />z.�,. Address tY <br />GIS Coordinates: X 'Vn Y AM� Township �`� Range _14-_ Section <br />WORK TO BE PERF9RMED: <br />NEW WELL /.BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />f�-� �.SOILBORING# 51 —I�� Sl�—�� aOVER-BORE <br />0 WELL # 0 PRESSURE GROUT <br />`Other: Grout Specifications: <br />COMMENTS: ,Z Q , ? i e n� s i I -2() ° l t c, ,". , jog' ci � � C' 201 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Lj "i MULTIPLE CASINGS? a YES Ig NO WELL CASING DIA: <br />0 EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: — Z, <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL !Zo' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: IgYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') 4— <br />''SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Nc'c u t <br />0 OTHER:�fI OTHER �C7Jl 1 L APPROX. BORING DEPTH 17-C, D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS:1�2.�1t� <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT NtKMI 15. <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, �R i s and Regulations, and all applicable CaliforniaStateLaws. I <br />Signed x jn�_ �u Title/Company <br />r <br />Print Name ll'C� C� t C Date ° <br />DEPARTMENT USE ONLY _ <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 3��8 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />Issued <br />Date Final Inspection <br />Date <br />X, 57q� <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / <br />15 2 t <br />C-57 WC V/ -WAIVER C-57 Letter of Authorization to sign permit <br />a'p� <br />-, -Z--a <br />EST # I INVOICE <br />9/27/00 <br />