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WELL PERMIT APPLICATION FORM <br />SITE <br />OCT 2 4 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />EI VIRC4i 11', EI T I- E.ALTH ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />PERP.,if T/ S F P I C ESS 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />AID# <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 />PE CODES <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />AMOUNT REMITTED <br />V", -j S o -Assessor's <br />HELL Location -3-1 3 0 Cross Street S . d11z�-1 lu City T� Zip RS 316 Parcel# Z.S S O L o 03 <br />REC'D BY <br />PROPERTY Owner Address 3�2O ��> L: oc-j CityTC, m e zips 3 l(�phone# g 33 7 S 1 7 <br />I99Z/Bi;/Z© <br />`a (� 1L Q O 1� J� y Si `s z ��o <br />City ZipB Lic#1 Phone#i <br />C-57 Contra r� +� t y Address <br />_ <br />�onsulta 15uE� 6ertorG Z�\ off' c �Q Te�%r Wddress \\01 —14K ST Cit��c�TJ Lic# — Phone#2 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />III, NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) p DESTRUCTION (choose type below) <br />a SOIL BORING # Q OVER -BORE <br />WELL # h�vJ 5 Q PRESSURE GROUT <br />'Other. Grout Sj�cifications: <br />COMMENTS: ,L�`�c;l <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />jj, MONITORING 0 HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? ]]YES O NO WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING Q STEEL O PVC, [] OTHER: <br />p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. p AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />a OTHER: 0 OTHER APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />,� ^ I �1 <br />*COMMENTS: 1 V17L+ 1,8� Ao,14A <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinan ul fS frLdgulations, and all applicable California State Laws. <br />Signed x r, Title/Company <br />Print Name \�� rv� \��� \� ,o Date O 1 Z l `O 3 <br />DEPARTMENT US <br />SITE MAP IN UNIT IV FILE, ADDRESS: 3 -7--8-0 L`c.w.­�LA�� <br />WORK PLAN DATED: b1 z� 03 4. g 1,6103 /4df,Ce", / <br />Application Accepted By Date Issued / O /Z D 3 Area 6 Zl <br />47 <br />Grout Inspection By Date Final Inspection By '(AAAC'C,,-, Data <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: I�iPa� 1�i1 P/bth2re�— /t/Yr�tl4 <br />ACCOUNTING ONLY: <br />AID# <br />Encroac <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE RMIT /SERVICE RE NVOICE <br />I99Z/Bi;/Z© <br />C-57_ WC -WAIVER <br />C-57 Letter of Authorization to sign permit_ <br />Encroac <br />ment doc <br />9/27/00 <br />Co 39�'d <br />2J0079 Hl_I� <br />EEbEB9bE9Z <br />99:Ei <br />I99Z/Bi;/Z© <br />