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12/03/2004 16:41 <br />209468'433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />FEB o A 2005 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PEr=,P, J/SERVICES (209) 468-3449 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRFS 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 appllcation is made in compliance with San <br />Joaquin County Development Tide, Chapter 9-1�0_415.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />G� Assessors <br />WELL Location Z2Sb ZOtA Z1itDor+ Cross Street 1 t City � t7vt Zip 15 Parcel# IbQ1'0�'rJr1 <br />PROPERTYOwn 1r =717 �yuet-D Address4 L4oLJeLtCaVArt_ :i CityO�i ZipLqg'�O Phone# Zc 41-9144 <br />C-57 Contract ryl tkell fir' Itlu�Addresse-1 f,00 'Mi V+Iel Aire ° Clty_!J AV CKLi Zlp9y�ic#%lPhone# �l Q0"'D <br />Consultant/ Sub Contra e�t�pPI�a.1 Q1(�a�1tt ��—A'dress ry"I 00t,Ap�4 Citv@lf .cio"tL # Phone Ib -Zl 0 <br />GIS Coordinates, X Y Township Range Section <br />WORK TO BE PERFORMED: <br />`kNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) Q DESTRUCTION (Choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />-AWELLP/ MW -5 _L�t 0 PRESSURE GROUT <br />'Other: tOF— �✓ t i�cl�a'IZ�6'c� 5 Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAk N$ <br />MONITORING `'HOLLOW STEM OIA. OF SOREHOLF-9 U MULTIPLE CASINGS? 0 YESXNO WELL CASING OIA: Z" <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNES95tkea.`fYp TYPE OF CASING: 0 STEEL )<PVC 0 OTHER: <br />— <br />a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 501 TREMIE TYPE TO SE USED: 'AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes *0 (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Y%eQj QCvV %A <br />0 OTHER: f1 OTHER APPROX. BORING DEPTH I `i BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? tJd ; (if YES, Ifst specifications here): <br />`COMMENTS 6&&, a4rAJ&aAyje-U- G Arm l_. A, L:a 9 V?l <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIVNS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordingnces, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print Na <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Title/Compan <br />DEPARTMENT USE ONLY <br />Application Accepted By C / Date Issued <br />Grout Inspectlon By If t, Date inal Inspection By <br />Destruction Inspection By pate —� <br />COMMENTS /CONDMONS <br />st/4067,.WET)O-P—t <br />ACCOUNTINOONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE <br />- .-SR#! <br />PERMIT/ SERVICE REQUEST # <br />INVOICE <br />C-57— WC -WAIVER_ C-57 Letter of Authorization to sign permit„.. Encroachment doc--___ <br />V <br />iN <br />