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WELPERMIT APPLICATION FORM <br />SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) o UNIT IV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />FEB 0 5 2002 <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 I�r�te$ETn <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, EnvironrrUe�PHe�ltti�DtiQ1EIS <br />WELL Location I (F' G4 S QLat, I'� �i S- k+ , Cross Street C K" w City J �c �12v� Zip Parcel# <br />PROPERTY Owner lwlo Address 160(r L Ckey Ee✓ U rCity. zipI � LC-'lPhone#Lfrl.6i4�' 'j <br />C-57 Contractor Ir(�Gll� •vl �u+Y�U (. Address jq� S. Vii.. ��v e� A City cJ%�rr�o: ZipjgXC4 Lic#✓E 31 Phone# 5(b• Z j 1. S�\ <br />Consultant/ Sub Contractor (senor. �j'o✓) Address �Zlo kl . n,-,,kei 6w.,k City S4'Z1,,yzLLic# Phone# qIb . 5(`IsA t`S S <br />GIS Coordinates: <br />, Township <br />WORK TO BE PERFORMED: <br />)LNEW WELL / BORING ((PPT, GEOPROBE, HYDROPUNCH, HAND -AUGER <br />0 SOIL BORING # <br />0 WELL # <br />OTHER*) <br />Range Section <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE O <br />0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: c n <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <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 />PUSH POINT <br />SOIL BORING <br />0 HAND AUGER <br />0 OTHER:_0 <br />OTHER <br />*COMM <br />DIA. OF BOREHOLE t.. MULTIPLE CASINGS? 0 YES L NO WELL CASING DIA: <br />CASING THICKNESS MQt1P TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL 10,C) (t TREMIE TYPE TO BE USED: 0 AUGERS if HOSE <br />GROUT SEAL PUMPED: 0 Yes )[No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 'IS j' -?j <br />APPROX. BORING DEPTH 1 (_ C. (( 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ii ( if YES, list specifications here): y <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 Regulations, and all applicable California State Laws. <br />Signed x 1� 4� (�� ^t y,;Title/Company rt r 1 �T O(Or�c17 1 <br />Print Name l (u/ I� _ til7n,- Date • Z Y• (37 - <br />DEPARTMENT <br />Z. <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I,I,G <br />WORK PLAN DATED: 4-cJ, `1 Z o D Z <br />Application Accepted By CA— Date IssuedoZ % /� Z Area <br />Grout Inspection By �L�1. 1� Date Final Inspection By �ZOA6ACc— Date j b7 <br />Destruction Inspection By Date <br />COMMENTS / CONDITI <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT REQUEST # <br />INVOICE <br />3S0 <br />0 <br />f �s"l <br />(,(Q <br />;?f o Qt <br />C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Enc T -d —oc 9/27/00 <br />