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Lic# Phone# 9/5 a'-o <br />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 />k ,Ic <br />t‘‘' M s.B <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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location C--04t'4e 4/14 -.X00,--/2 -577 Cross Street City ...5rev-ie/V/1/ Zip Parcel# <br />/two <br />PROPERTY Owner Girt' a iz --S"7acie-e-v4/ Addressga5-/i4 g/A4o261, Si,— City .5;z,e—AereW Zipf5-202--Phone# <br />0 5-46g <br />C-57 Contractor ,./342."../iv Address 5r-0 /441‘ .401", City/7/gRAir-a Zip *IV Lic# Phone# 90-5---79--571ao <br />Consultant / Sub Contractor -ri3/-7xe/titTANierdress 7/7 /J41- eZ. P City 60/2.400i <br />-Alvo <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />)(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />[] DESTRUCTION (choose type below) <br />[] SOIL BORING # <br />[l OVER-BORE <br />[] WELL # <br />[] PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS: <br />Assessor's <br /> TREMIE TYPE TO BE USED: NAUGERS [] HOSE <br />GROUT SEAL PUMPED: [] Yes [] No (NOTE: MA)i!l4AU FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: #4/0 <br />4‘,..C. <br />,47 - <br />APPROX. BORING DEPTH -5; XiOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? AIO ( if YES, list specifications here): <br />*COMMENTS: ,Y 14/-4-/._.5 re, z? 7;<e <br />- /4"-- t,g/"7-7. UCN to el t 0 hi CAte 110 5 b-2,A ; dut-e,Adst. 1z44-1 Ct S-g. <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, ul s and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />TYPE OF WELL INSTALLATION TYPE <br />XMONITORING )(HOLLOW STEM <br />[] EXTRACTION [] AIR HAMMER/DRIVEN <br />[] VAPOR [] MUD ROTARY <br />[J AIR SPARGE [] PUSH POINT <br />[] SOIL BORING [] HAND AUGER <br />[] OTHER: [] OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE /0 MULTIPLE CASINGSWES [] NO WELL CASING DIA: 6-- <br />CASING THICKNESS *it tea TYPE OF CASING: [] STEEL ).'PVC [] OTHER: <br />DEPTH OF GROUT SEAL <br />Title/Company 5,-CC2.e-- ...2.5e7e,•64/1770/1/.1-- <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2-0 C <br />WORK PLAN DATED: 3/ 2--/c'z..tswet.7f c.,06,1,;•;,c,ftiLt _d_cvt( <br /> <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br /> Date <br />Date <br />S" <br />Date Issued s-1 /40 'el._ Area <br />Final Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# CA044. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE - PE QUEST # <br />a cgisz_ <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign p <br /> <br />9/27/00 <br />