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_ KNELL PERMIT APPLICATION FORM CITE <br />�° ECE� V f�C,i TlON <br />AMiT1G <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT A <br />JAN 3 0 2002 ENVIRONMENTAL HEALTH DIVISION (PNS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT HEALTH (209) 468-3449 <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 construct and/or install the work described. This application is made in =mpliance with San <br />Joaquin County Development i itle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />t�c _ AssessoCs <br />WELL Location 1� � i 71 J Cross Strut/ +L.14 City � � Z c Parcel# <br />PROPERTY Owner �1 61 �' r��f ` AddressY45 / `P ° a l Z 5Tity 5 � zlp�hone# <br />C-57 Contractor 41"J) ir7f: J Address �j l j �1�lt,�i /�X, City /�1 7 _-L ia#�`�SL Phone# <br />Consultant 1 Sub Contractor Address C,ty Lic# Phcne# <br />GIS Coordinates: X , Y , Township Range Section <br />W RK TO BE PERFORMED: <br />NEW WELL /BORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />OIL BORING # 0 OVER -$ORE N1, <br />LL #nL Q PRESSURE GROUT ,- <br />*Other. Grout Specifications: ! 1 J <br />CCM TS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HCLLOW STEM <br />0 EXTRACTION <br />❑ AIR HAMMERIDRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />REC'D BY <br />DATE <br />0 AIR SPARGE RUSH POINT <br />k&IL BORING I] HAND AUGER <br />IJ OTHER:_ _I] OTHER_` <br />_I <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE/KL +I MULTIPLE CAST YES 0 NO WELL CASING DIA: <br />CASING THICKNES9%S?9 TYPE OF 22M. '[]STEEL KPVC 0 GTHER:___,. <br />DEPTH OF GROUT SEAL L ✓J -r) L1� TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes ,(No I(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: nc.✓L+4� <br />APPROX. BORING DEPTH �iG r�Z7T D BOLTED TRAFFIC SOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if <br />list specifications here):___ — <br />klrlT=- nF:I=gITF RFaWRE ACCESS OR ENCROACHMLN I rtrcml I Z1. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FUK ALL K1=WU1Mr-L ��.�r =v 1 <br />I hereby certify that 1 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 />Title/Company <br />Signed x <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: �` a-5txj'%�j �'!"� �� � ✓ 7i` � � - - <br />WORK PLAN DATED: & Att; 5 <br />Application Accepted By Date IssuedI ! I h Area <br />Grout Inspection By �ip Date `l Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit tncroacnMenT aoc_ 7r � <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT SERVICE # <br />'INVOICE <br />5 0 <br />r Cts <br />1 <br />14 I <br />Z 02- <br />//REQUEST <br />� b <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit tncroacnMenT aoc_ 7r � <br />