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A02 08:18 2094683433 FIFTH FLOOR r'Aut nZ <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />i1. ? " <br />-NOV 1V3 2002. <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />NON-REFUNDABLE PERMIT ExPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to oonstruct 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 Environmental Health \ Department. <br />C_ Assessors <br />WELL Location it?Iwy. ps1 "'f._ Cross Street City Zip Parcel# i6 i-O3o-OL( <br />PROPERTY.Owner �r^r.alu= Address City ZiPhone# <br />r r' S r r `1T �t 4\ -' I <br />C-57 Contractor �R6t �c ->4 =�� s� Address 3fl 11 �J, �� �F�i� kv- City `^�� K Zip `3< (� l Lic# t = - Phone# <br />Consultant/Sub Contractor Addresscj=� ll� . jCity�'r Lilt Phone# SkiI�iQ7 <br />GIS Coordinates: X , Y Township Range Section <br />WORT TO BE PERFORMED <br />W WELL / BORING((EOPROBE, HYDROPUNCH, HAND -AUGER. OTHER`) Q DESTRUCTION (choose type below) <br />0 SOIL BORING # Q OVER=BORE <br />rl WEL.L#_ Q PRESSURE GROUT <br />`Other. Grout Specifications: <br />COMMENTS: t=F 1 -•-1 U tit <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />Q MONITOPING n HOLLOW STEM DIA. OF BOREHOLE I " j "' MULTIPLE CASINGS? AYES ,j(NO WELL CASING DIA: Nt�"i <br />fl EXTRACTION t) AIR HAMMER/DRIVEN CASING THICKNESS pjc_ TYPE OF CASING: a STEEL Q PVC Q OTHER: <br />FEE INFO AMOUNT REMfITED <br />S VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 'Q AUGERS `"OSE <br />DATE PERMR f ICE T # INVOICE <br />nl AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: Ye5' WN* (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />rl SOIL F30RING nl HAND AUGER GROUT SPECIFICATIONS: <br />III a sRS PO -9 50Z <br />n OTHER; 0 OTHER APPROX. BORING DEPTH i (7U ' (] BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NU (if YES, list specifications here): <br />-COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THF I ]NIT 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 />Countlyordinapces 4ales and Regulations, and all applicable California State Laws. <br />Signed x TitlelCompany <br />Print Name {��L +bA���Sc+v _Date �41� �a <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATEb: Q <br />Application Accepted By 'l Date Issued Area <br />Grout Inspection By Date Final Inspectlon By Date <br />Destruction Inspection By Date <br />COMMENTS ! CONDITIONS: <br />ACCOUNTING ONLY: AIDff Ferry <br />PE CODES <br />FEE INFO AMOUNT REMfITED <br />CHECK # REC'D BY <br />DATE PERMR f ICE T # INVOICE <br />U-""— <br />III a sRS PO -9 50Z <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ent doc iicoiuc <br />