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WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI (` TION <br />0% <br />ENVIRONMENTAL HEALTH DIVISION (PHS -E, <br />IV (.oC <br />304 E. Weber, Third Floor, Stockton, CA., 952 ��II <br />(209) 468-3449 <br />NON-REFUNDABLE PERM17 EXPIRES 1 YEAR FROM DATE ISSUED /�1�1/✓ <br />Application is hereby mace to San';caq.;in Ccun:; for a Perm ::c cc'-st•_C an ^stall :he wor'K �escnte:d. This appiica:.o'1 is mace zomp'iance'�':;h San <br />Joaqu,n Coan:y Ce+,elcprent T r.le, Chapter r-1 115.3 ano :te Stancams of San J--a,--,n Cour,i), FJolic -ea: :h Seryces, En, r_^n e-:af Health Civsion. <br />Assessor's txtle�x n <br />WELL Location 1904 CCUrltrY Club Bhd. Cess S: ee: I11-SSlo1 _Cid, <br />PROPERTY OwnerSih �/QQgUr ,'/ C.OUhX)!^db'ess A/e-C,ty rn _Z , <br />C-57 Contractor V8N 11'i 11 it eg IM Adcress P.O. FDX 51 O ly Rio Vista Cio 94571 L c_ 72C94 =hznez 707 314-2815 <br />Consultant/ Sub Contractor Acdress 1�6 E. Beaner Sl� City �'1�Li:# 513857 Pere- 530 668-5300 <br />GIS Coordinates: X _ Y To%rsh-o 1N Rance 6E SecJon 4 <br />WORK TO BE PERFORMED: <br />NEYJ YELL / BORING ( CPT, GEOPROBE. H�CRC=L^.'CH, HAND -,USER. OT"ER') p D_S-F CT 0\ (= Dose type belcw) <br />g SOIL eCR:N'G = 7rRp OVER -BORE <br />)}WELL PRESSURE GROUT <br />'Other: G -o,: Spec:Soal;ors: _ <br />CCMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />�MONITOR!NG ' �J-iOLL'O1N STEM CIA. OF BCRE'"OL"c_� h'. ! `IPL= C.�SINGS? 0 YES 'O 1'vE:L CASING riJ.4: oZ,//�, <br />0 EXTRACTION i' 0 AIR HA1.irAER1CR!V=N CAS NG Tr !C,<FtESSC� TYPE OF CAS!NG: p STEEL 8�=VC () OTHER: <br />O VAPOR 0 MUD ROTARY CEPTH OF GROUT S � TREMIE: TYPE TO aE :.SED: ] ALGERS �HCSE <br />O AIR•SFARGE p PUSH POINT GRO:iT SEA'_ PJMPED. Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />SOIL BORING p H. ND AUGER GRCJT SPECIF CAT 0\S NeatCe7137t With 5% bentcnite <br />0 OTH;EZ: 0 OTI-ER APPRCX. BCR!NG D=F-- „kr ;BOLTED TRAF= C EC•X or p STOVc P:PE <br />CCND'JCTOR CASAE n<OPOSED?rte_ (;f YES. I,st spec f:oa!,ons here): r <br />'COMMEN <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 ! have prepared this application and that the work will be done in accordance with San Joaquin <br />County OrdinAryces. RuIP p^^"'- -is, and all applicable California State Laws. <br />Mored z / z� �?yYv-cu-L -.. e'Co.Tpa^yWestem G n—e <br />Print Name L. CCnverse Cate -.Z6 --.20o / <br />- DEPARTMENT USE ONLY <br />/y <br />SITE MAP IN UNIT IV FILE, ADDRESS: G P�• �i �`""` <br />WORK PLAN DATED: ,-, , ` if-" '6 7-C)Oa — ud <br />Application Accepted By, <br />Grout Inspection By_ <br />Destruction Inspection B <br />COMMENTS !CONDITIONS: <br />Date !ss -..ed <br />Final Inspection By �►►,, <br />61, <br />i• Y—/—O/ <br />ACCOUNTING ONLY: <br />AID, <br />_ <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK x <br />I <br />RECD BY <br />DATE P ICE 7 # <br />INVOICE <br />C-57 WC -WAIVER C-57 Letter of Autncrizc, icn to sign permit _1:­ncrocceiment eoc_ V/4 //UV <br />E3 .Std j�•QZ <br />p�Q O ce G/• S o I -c e <br />y ^�- o(�ic� _y�X3(o� <br />C> / pct l s /�uw, 5P 5 / A,iW IS <br />