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o6FY <br />te <br />Area <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />DEC 0 7 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 6-f, <br />ENVRL,H HEALTH (209) 468-3449 OF/ <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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location 5/5 / NC I c IC 4 v. Cross Street)10 KuTs City StoCkteM Zip 7520 7Parcel# /08"/ bo -0 I Assessor's <br />Sa.)4 lbacku s l''‘ <br />PROPERTY Owner De 1 t tt N'oileae Address Sh,YrIt City Zip Phone# 20 05 St' 503g ( k <br />C-57 Contractor Y4 1J D ts).1] I Y13 Address 100 5-th St V•te t City ,r5 itt0AZip Y56 tdic# 702?Olkone#?/4./777-q107) ‘• <br />Consultant / Sub Contractor EnVitY))174ENAttli 4daddress (01204 (9rtec a Llayit y_pkg_GLic#60063Y8phone#710301-g°6-2/ <br />N <br />SITE <br />MITIGATION <br />UNIT IV <br />--- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RaJd <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PE ED: <br />CPT, GEOPROBE, HYDROPUN , HAND-NGER, OTHER*) <br />XSOIL BORING # S <br />u WELL # <br />yt NEW WELL / U DESTRUCTION (choose type below) <br />[] OVER-BORE <br />U PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br /> <br />0/10NITORING X.HOLLOW STEM <br />Li EXTRACTION 0 AIR HAMMER/DRIVEN <br />U VAPOR [] MUD ROTARY <br />U AIR SPARGE [1 PUSH POINT <br /> <br />,ASOIL BORING a HAND AUGER <br />a OTHER: a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE /'" MULTIPLE CASINGS? U YES a NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: [] STEEL [.] PVC OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS U HOSE <br />GROUT SEAL PUMPED: U Yes [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH /0 ceet- U BOLTED TRAFFIC BOX or U STOVE PIPE <br />CON UCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: G rlDut• to LuZite..... crxt c1:5-42- .4.44.1.t.,4 <br />t; <br />NOTE: OFISITE 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 Or• nances, Rules and Re ulations, and all applicable California State Laws. <br />/ev/A,e,szomixt24t,U CetatiLL- Title/Company <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 54/06) .6-edt_e — S - /a <br />WORK PLAN DATED: /2-- Cp-0/ <br />Signed x <br />Print Name v.emE Ivied-) vvvi <br />Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br />dr <br /> <br />,bra; <br /> <br />WLTIAPON <br />Date Issued <br />Date <br />Date <br /> <br />Final Inspection By <br /> <br />COMMENTS / CONDITION <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE RO4JT # INVOICE <br />iciiv sR# oozgz.(02__ _ <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit 9/27/00