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WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />FUNIT IV <br />APR 1 8 20 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMEN IL cfc S <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Ftrifiade in compliance w <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County_Public Health Services, Environmental Health Division. <br />li•.ebowat, vG hr Assessor's <br />WELL Location a 40414 Ae .,4 Cross Street <br />L <br />City )focAficivi Zip 95207 Parcel#1:641MMN <br />PROPERTY Owner elk/ 0 i.c7 /010 4 /6 )1 Address Li)..5 /v. 47 aviodo Ci ty 5 foc4 kin zip95.2a2 Phone#(2°9.)7.??-61513 <br />C-57 Contractor,, dkgy 7-0-4;77 Address q5.0 /1004..e ifOqd City/AP-71/46'Z Zip 916.53Lic#656 ,70?Phone# (925)3/3 "Stlitt/ <br />Consult ant / 3ut, traietur tkeileAn 6.6b- .17. Address )386 b": Necikine A. 5-71. City Woadkvw/Lic# 5/385? Phone#C570)66-P-.17.?0,0 <br />GIS Coordinates: X , Y . Township 2 /1/ohlk, Range C Section 2 / <br />WORK TO BE PERFORMED: <br />XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNC1, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />'SOIL 130RING # Se X C. CP77 ) 0 OVER-BORE <br />, DWELL # ....„...,, ....,7 / 0/C-,‘ 7e 6:*04,ae,.44.4.4 0 PRESSURE GROUT <br />"Other: If se? .1;‘Cki $eGA-e-fftst "A4La A- ck.ds 4rhy),~1 Grout Specifications: <br />COMMENTS: CPT 40 Pi.5. lad A.A. obl-ced, hydm,cmA 6,-,c(716- foofse --r 4=v04 "Accenc/c,-q'4"-- rcwe I /9 <br />Q TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1" MULTIPLE CASINGS? 0 YES g NO WELL CASING DIA: <br />U EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />[] VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE N PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />[] SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS: <br />BOTHER: ce 7 0 OTHER APPROX. BORING DEPTH I La cee-A fi BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />Title/Company VA Gpemarkiii Ceo. . <br />Print Name Date <br />CONQUCTQ CASING PR <br />1,/,t,*COMMENTS: OPH <br />Ziroa YC) <br />NOTE: FSITE BORINGS REQUI <br />6.444fre_ <br />SED? ( if YES, list specifications here <br />'a N e6L <br /> <br />.6voy <br />E 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 Ordi nce Rules and Regulations, and all applicable California State Laws. <br />Signed x drelet—ev—C-- <br />Ce.ae CCP/1.1:0:k <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, V2ESS: <br />WORK PLAN DATED: <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br /> <br />Date Issued <br /> <br />o Area <br />Date <br /> <br />Date Final Inspection By <br /> <br />Date <br /> <br />ACCOUNTING ONLY: AID# <br />- <br />FAC# <br />-.... <br />/ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ..„.E.E.'SERVI.C.E. RMTh t INVOICE <br />350 / Z13 SI 5°46 eal. 1/1F-9C sR# 6 L5e90 <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit --je—Errereethreterrl--ttg-C" 9/27/00 <br /> <br />513 3.9VcI EEVE8SVE.13Z ES:OT 000Z/ET/OT