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RDECENEID) WELL PERMIT APPLICATION FORM <br />FEB 19 2004 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENW MIT ENI HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />pE'{1�1?ISERVICES (209) 468-3449 <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 />I Assessor's <br />WELL Location 506 EgsT L ows /l}U�L4e Cross Street 5 1 ZZ)A(; ST.City LATH 120 P Zip 75330 Parcel# <br />PROPERTY Owner <br />pAwt�,ThN A)OQ.TiiANAf3iM Address VIAIA015W- P-6 J CJ 799 City Zip "13497 Phone# <br />C-57 Contractoryb It) P_Mt.IIUG_ ddress Po �Roy q/6 City <br />-JSL�7oI�J�Zip95�,`fl Lic#72696Phone# 9t6 777"�VlIDO <br />Consultant/Sub Contractor j!fouLtj�-E.40fl'Fr;e_q Address 188F04A1YU STfjWj6;tysii 7b -U Lic# Phone# 23+1 DS1y <br />GIS Coordinates: X Y -Township I S Range g Grp Section .35 <br />WORK TO BE PERFORMED: <br />0 NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 SOIL BORING #, <br />0WELL # I d I U� ( ' <br />`Other: Grout Specifications:_ <br />COMMENTS: 7-wo OKJl7-OAx1AA6 W61 -L -S `Tb a6 „lo6STgby&4 17- <br />21 VtESTRUCTION (choose type below) <br />0 OVER -BORE <br />ZVFrRESSURE GROUT <br />E . <br />`S <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 Ordina es, Rules and ulations, and all applicable California State Laws. <br />Signed x_ //'' /� _Title/Company 7 <br />Print Name 1 sq'; N /� ! _ _Date ' D? <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 50 6 <br />WORK PLAN DATED: t/ <br />Application Accepted By Date Issued a2 � a �l Area 7 Y <br />Grout Inspection ByDate _Final Inspection By Date <br />Destruction Inspection By l ' %i�� �. Zt.c' Date 3 G C,' �XCC, t �.! 1G,1 v (C: %�f� ii�� flt-� /vr Sok - i ! + <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />- <br />AID# <br />) /.`3' r �• II <br />PE CODES <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />REC'D BY <br />?)(MONITORING <br />HOLLOW STEM <br />-- DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES WELL CASING DIA: <br />PVC OTHER:_ <br />35oa. <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 0 <br />x(315 <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL O -,U ) TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED: $Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: < 5 9v t3EAvM;CtffE 1 yPg; T&grAC- +4r <br />0 OTHER: <br />___0 OTHER <br />_ APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here):____ <br />*COMMENTS: <br />/CJ4 TJ�KD 42-F <br />r <br />Z MW I70,kJAL 4 UX1.4-5 ID 86-D1-L9R 44 ��/ Aj4sUl2&62lXC� <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 Ordina es, Rules and ulations, and all applicable California State Laws. <br />Signed x_ //'' /� _Title/Company 7 <br />Print Name 1 sq'; N /� ! _ _Date ' D? <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 50 6 <br />WORK PLAN DATED: t/ <br />Application Accepted By Date Issued a2 � a �l Area 7 Y <br />Grout Inspection ByDate _Final Inspection By Date <br />Destruction Inspection By l ' %i�� �. Zt.c' Date 3 G C,' �XCC, t �.! 1G,1 v (C: %�f� ii�� flt-� /vr Sok - i ! + <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />- <br />AID# <br />) /.`3' r �• II <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />Pc M F S€RVICEREQUEST <br />INVOICE <br />35oa. <br />(o <br />4 GO <br />x(315 <br />SR# 3?0� <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/Z//00 <br />