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WE"L PERMIT APPLICATIONOORM <br />DEC 1 0 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIBONIt iL= .' ! -1'11 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />PERMIT/'SER 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 488-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 Compliance with San <br />Joaquin County Development iltle, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />(' Assessor's <br />WELL Location ) - � L'N Z ro (CPE La ri t Cross Street L b0c. 0 �+ City e K 1 zip�iS'___� �__Pareet#- 4' y J y D " <br />PROPERTY Owner C �Y+ I [ ►n 5ICt Address Tu c I:� - Cc., City J's / ' �Z1p ?a�Phone# t17 <br />; <br />C-57 Contractor (>.cL�<%�C' W1 -5 1'4- -Address GSU 14t)v e Pc) City l b ZipL�uc#LS 07Phone#. <br />/� _ I /+- J <br />Consultant) Sub Contractor _ * 1{; Address 5 `> Ince'" �c Crtys C Y Lic G�,�� Phone#&�!%'� 7 �Uy �' <br />GIS Coordinates: X <br />, Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />EW WELL / BORING (CPT. GEOPROBE. HYDROPUNCH, HANDTAUGER, OTHER') DESTRUCTION (choose type below) <br />_A—t <br />E <br />OIL BORING # [ F) PRESSSURESURE <br />PRGROUT <br />RE1�CID BY <br />0 WELL # <br />0 <br />'Other. <br />Grout Specifications: <br />COMMENTS: <br />�`i Z-1 <br />�"'" <br />r� 0 <br />/� ] 2 <br />Vel � /� <br />nin-f <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />j] HOLLOW STEM <br />DIA. OF BOREHOLE -71" MULTIPLE CASINGS? a YES Q NO WELL CASIN _ <br />0 EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />CASING THICKNESS Jl TYPE OF CASING: 0 STEEL [IPVC BOTHER: - <br />OTHER:_VAPOR <br />VAPOR <br />Q MUD ROTARY <br />DEPTH OF GROUT SEAL/ iREMIE TYPE TO BE USED: 0 AUGERS -R HOSE (� <br />�o <br />0 AIR SPARGE <br />POINT <br />GROUT SEAL PUMPED: gYes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />_ SOIL BORING <br />/-ff�USH <br />]] HAND AUGER <br />GROUT SPECIFiCATIONS: rly 00 d4 Ilk <br />0 OTHER: (] OTHER_ <br />APPROX. BORING DEPTHJ� j] BGLTED TRAF=iC BOX or 0 STO/V PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />.. <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />7 e7 <br />DEPARTMENT USE ONLY <br />0) <br />SITE <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted BDate Issued ( D Area <br />Grout Inspection By <br />�s� Date/? 71-101. Final Inspection By i Date/ Z 20 n <br />Destruction Inspection By Date <br />nun ^Ue. <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit �EncroachmenT aoc 7� / <br />ACCOUNTING ONLY4'AID# <br />PE CODES <br />FEE IAMOUNT <br />REMITTED <br />CHECK # <br />RE1�CID BY <br />DATE/ <br />ST # <br />INVOICE <br />�`i Z-1 <br />�"'" <br />r� 0 <br />/� ] 2 <br />Vel � /� <br />nin-f <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit �EncroachmenT aoc 7� / <br />