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07/19/2002 08:18 2094683433 FIFTH kOOA PAl 02 <br />WEL.. PERMIT APPLICATION F jRM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468.3449 <br />SITE <br />VO <br />V <br />--W,,,; 3 2 2002 <br />i__-NVIRONMENT <br />002 <br />i=NVIRONMENT HEALTH <br />NON-REFUNDABLE PERMIT IBES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 Tkle, Chapter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br />-- • Assessor's <br />WELL Location �s t s I:- Cross Street City tri �>�rr_,., Zip a��OD� Parcel# 1 Es I -0'30-Oa <br />PROPERTY, Own <br />Address 4369 Ci3y t,,g__W Zip 1--10 Phone# 42.5 '&i4 -•23$S <br />C-57 Contractor KE'�o�s�i�clr�azr�id��� Addresses li-i Lft&T Sr city ZipiS (-1UC# -3_r Phone# <br />Consultant / Sub Contractor 1) N j _Address _M < _Sj--w 2xity 0Ai:.I-A4jCUc Phone# SlL 7-13- 4r-LaO <br />GIS Coordinates: X Y Township Range Section <br />W TO BE PEREORMD: <br />NEW WELL /'E30RIN ( CPT, GEOPROBE, OPUNC , HANO-AUGER. OTHER`) a DESTRUCTION (choose type below) <br />0 SOIL BORING # a OVER=BORE <br />r-1 WELL #_ p PRESSURE GROUT <br />`Other. Grout Specifications: U� <br />COMMENTS: UP -fit, mw1•,`.Itp—�-'j <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITOPING <br />0 HOLLOW STEM <br />n EXTPACTION <br />n AIR HAMMER/DRIVEN <br />Il VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />�vIL PORING <br />rl HAND AUGER <br />P OTHER: <br />ROTHERSW9WF-- MC <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE 1-i MULTIPLE CASINGS? 0 YES 6NO WELL CASING DIA: <br />CASING THICKNESS UG TYPE OF CASING: 0 STEEL 0 PVC [] OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: .0 AUGERS 9HOSE <br />GROUT SEAL PUMPED: 11 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS:- <br />APPROX. <br />PECIFICATIONS: <br />APPROX. BORING DEPTH'fi'O ' 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 1,_9( if YES, list specifications here): <br />*COMMENTS. `1 vrysUtz oru-r. Sru� s esc,A� l� <br />MOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br />CALL THF 1_INIT IV INSPI=CTOR 49 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County OrdinanGps, RAes and Requlations, and all applicable California State Laws. <br />Signed <br />Print <br />DEP <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED. <br />US <br />4 <br />Application Accepted By CL�� Date Issued_- I �(/b L Areaw0�a CIT <br />Grout Inspection By. Date L Final Inspection B r Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />Far.rt <br />PE CODES FEE INFO <br />AMOUNT REM] TIED <br />CHECK # <br />REC'D BY DATE PE CE # <br />INVOICE <br />C-57 WC` -WAIVER C-57 Letter of Authorization to sign permit nc en doc 1/25/02 <br />