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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />MCD ECEI <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />l 1! �\" I 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />APR 2 8 2004 (209) 463-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />r, NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Aopiication.jji 4febyt�d4iol�Ab1k li!Iuin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin CourRty-q,8w���1�G�I��Ghapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location //STOW , E/6#7' M'CC K D Cross Street City S , oe/GTCi✓ Zip Parcel# <br />PROPERTY Owner LJESTAEC- P�t0PE47'1(:-C Address 1000 (A)• f:t.-'y I Z City LoD � Zip9S.24/2 Phone#26? 10411 <br />C-57 Contractor G,�E C-, Address 9ScD NDc�C- Z� City,eAgr 6 ,ip 33cic#Phone#9253/3S�O c0 <br />Consultant / Sub Contractor 4-rc AS roc1AT(5S Address lll7 LDJE 64C f" City Mo DEsTo Lic# Phone# <br />GIS Coordinates: X <br />Y <br />, Township <br />WORK TO BE PERFORMED: <br />NEW WELL T GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />gSCIL BORING # -2 B4;54,.vr1` <br />/[[I WELL # <br />*0+har- <br />COMMENTS: xvx SVGS✓ <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: <br />;OTHER D /PQGc.T' <br />'Pu s /V <br />'COMMENTS <br />Grout Specification <br />CONSTRUCTION SPECIFICATIONS <br />Section <br />0 DESTRUCTION (choose type beloV) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />DIA. OF BOREHOLE ,Z � � MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH /00 ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances Rules and RP�gulations, and all applicable California State Laws. <br />Signed x <br />^�/ // d17G iSo c /i( TES <br />.1 „��:= � Title/Copany��s%e <br />����� m <br />Print Name H� �� '� Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: 0&7"— <br />Application Accepted By_ <br />Grout Inspection By <br />Destruction Inspection By <br />3v al - <br />Range <br />Issued ` D <br />y'=DaDate Final Inspection 6F'-- <br />Date <br />te 400.._ <br />COMMENT5 / CUNDIFIUNS: <br />ACCOUNTING ONLY: AID# F u <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / VICE REQ # INVOICE <br />3 8 �� 2ER 6 <br />WC ✓ -WAIVER C-57 Letter oT Authorization to sign permit Encroac men 9/27/00 <br />