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WEL PERMIT APPLICATION FORM <br />REE; C 1E �, V1 E V` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />MAR 17 2003 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />NVIRI�NMENT HEALTH (209) 468-3449 <br />PFRMIT/SERVICES <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location �L� L/;/E; ><y > /��rZ i Cross Street �V- L1AR rGT City ) %fie h T�� Zip � 2 J ' Parcel# I %'7 -J7`/ 07 <br />PROPERTY OwnerT4 Address II qiJ S 1,`iY/7v j(l) City :�'i ��C� Zip %3A_ Phone# S 7 _40 <br />C-57 Contractor &4564OZ D Ll , Address 76jZ- JhGG G-iIZC LL City ►'y��`/h�u�"Ziph Lic#1_L%S�OPhone# LJI ;V— <br />Consultant/Sub Contractor SN+wG�+1//% Address/�jLC.Z.f�f��'/��lfl��4ityS/'-ti�ic# Phone#1'l6�rZ-1 33-:12 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />WELL # //I k/- 2-a 0 PRESSURE GROUT <br />*Other: <br />Grout Specifications: <br />J.,. <br />COMMENTS: <br />K., <br />` <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />�WONITORING <br />'THOLLOW STEM <br />DIA. OF BOREHOLEi._� (MULTIPLE CASINGS? 0 YES h�NO WELL CASING DIA: � <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS SIC/f 41) TYPE OF CASING: 0 STEEL JkPVC 0 OTHER: <br />[l VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL '- / / / TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />�. <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: 0 Yes ,[ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: 6_4F,lC- A,'- <br />[] OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH ; �' OLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED ,,/7 ( if YES, list specifications here): <br />*COMMENTS: <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 h <br />County Ordinanc,lR <br />Signed x <br />Print Name \j L (_L7_ <br />prepared this application and that the work will be done in accordance with San Joaquin <br />and Regulations, and all applicable California State Laws. <br />�q f <br />Title/Company C� (C�l �l OI'1J 1 1 61C Cc6 L-C� f <br />111�% CZ p Date LI �r t <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 515 t_/ <br />WORK PLAN DATED: /q RRIL <br />Application Accepted BI,IZn i4 -6=vA Date Issued Area <br />Grout Inspection By Date Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITION <br />ACCOUNTING ONLY: I AID# <br />)t <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />C-57_ WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 9/27/00 <br />