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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 - 102) <br />I ow . / <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <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 />WELL Location 033 cc Cross Street / City 0Cf-6\ Zip SZO1 Parcel# <br />A <br /> Li ID-A-46 <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />PROPERTY Owner Cioeo eon Padkcts AddressPef (k)‹ (Caj-i City Cv•- ?-e-0•61-‘ Zip 94583 Phone # -7(05-5- <br />ea P l y_1 11 <br /> :A CI <br />Assessa <br />.Contractork ell e_iti <br /> <br /> Addresg .0% 31 1..\ 0 Ci6\0011MiZiAC-511(iLic#34ari Phonefe-)20LOUN)- kllie <br />Address WO V.Ag,-re2la) City Cita-c)t,v‘L -r, Lic# 45-11/18 Phone# 9 kcsol -con. Consultant I Sub Contractor aCC) 9-.., <br />WORK TO BE PERFORMED: //V -5 /ro 23/46- 7 - - /3--. /0'66 <br />GIS Coordinates: X , Y , Township Range Section <br />X <br /> ESTRUCTION (choose type below) f] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />El SOIL BORING # 0 OVER-BORE <br />if OVELL # Ot-3 - % RESSURE GROUT .6-- <br />'Other: Grout SpeQifications: C' COMMENTS: k„)Q_ v1/4 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLL•W STEM DIA. OF BOREHOLE Uetk.to 6., f‘ MULTIPLE CASINGS? 0 YES 0 WELL CASING DIA: 1.191/ <br />4) D EXTRACTION u a MER/DRIVEN CASING THICKNESS TYPE OF CASING: TEEL D PVC 0 OTHER: <br />G VAPOR a , r 4: ARY DEPTH OF GROUT SEAL V(14-0L,.)A TREMIE TYPE TO BE USED: I] AUGERS 0 HOSE <br />[I AIR SPARGE a PU H P• INT GROUT SEAL PUMPED: u Yes 9 No (NOTE: MAXIMUM FREE-FA)..L DEPTH IS 30') <br />11 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ? usQ-1.1‘,,te, Cf-1(tA.A.- L31 j\ku.-k- C_L_,Nivs42•+;• <br />THER:i17 .-(_. a OTHER APPROX. BORING DEPTH ( / OLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? t\,) IN, ( 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules nd Regulations, and all applicable California State Laws. <br />Signed _.-- Title/Company Elm A ae. 6 A * <br /> <br />4111m. .. <br />Print Name 1. ‘7.1ny-oi-ctr\1,nw S Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 6&..3.3 7 4 42e,e; 211---- <br />WORK PLAN DATED: //- Z /-- 0 0 — 02. '1- "IfiLte'Vt40-, ' /64) <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />I ACCOUNTING ONLY: AID# <br />FA('# ------- <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P MIT / SERVICE REQUES INVOICE <br />i 30 2- /d a ee" a.c& <br />. <br />SR# 06 2`t19° <br />Date Issued Area 460 <br />Final Inspection By <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ---ERruarfirmerrt-doz" 9/27/00 <br /> <br />6E17E89176K TC:ET OOOZ/VO/ZT NOO-U KLAIA CO 39Vd