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<br />ORIGINAL <br />' hai_111 <br />WELL PERMIT APPLICATION FORM r YH <br />SAN JOAQUIN COUNTY MIT16010N ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 03 AUGUNI. Wi+: 24 <br />(209) 468-3449 <br /> <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 Environmental Health Department. <br />Assessors <br />WELL Location 700 -N.A. I A-) Cross Street C-P1/44"64"6 6-City Lbriltit-4'141 Zip "tj (" Parcel# <br />PROPERTY <br />Owner C ‘1-sf ° 1-e Address I s- "1) (-'`°P Zip 4i S-30 Phone# (7°1) TSTC - 2 /1-6 o X 32C <br />C-57 Contractor CA-54-",-r-7- 0644-`-`/-k3 Address 14' 11- oisk ‘1 (4-L kr City Zip 1 5"2-Lic#.7 I'79a Phone# ( /16 6 3 - I ) <br />C 1'16' 8-61- Consultant/Sub Cntr '` StIt to-4- -P a't"-'1••1`1'-'"•Address Sc't 16 100 City to•'-a"4 Lic# Phone# " °° <br />GIS Coordinates: X 4`i ,Y tt" , Township '' Range <br />WORK TO BE PERFORMED: <br />R.NEVV WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br />a SOIL BORING # a OVER-BORE. DIAMETER <br />'WELL # M - 6 a PRESSURE GROUT <br /> <br />th a *Oer GROUT SPECIFICATIONS <br />COMMENTS: (4 e. 1.4"-...co .x."‘CO -rbs. cc. it,Gs- /1.'9 In) chre,(sA-x,6.7 sl`n-c-"-,1-i-7 -P,CA <br /> <br />Sf •••••6‘ AAA C <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING g HOLLOW STEM DIA. OF BOREHOLE fl MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 5". 4° TY/PE OF CASING: 0 STEEL 14-PVC a OTHER: <br />j VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL 't"--9-1 Z TREMIE TYPE TO BE USED: XAUGERS [il HOSE <br />g AIR SPARGE/ OZONE [I PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes '11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />U sr.. .,.. BORING B HAND AUGER GROUT SPECIFICATIONS 11> 1 2 A-7v13.... ITC <br />U cr. tER: i] OTHER APPROX. BORING DEPTH 2- S' ipBOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED P' 0 (if YES, list specifications in comment section) <br />coi„,,A ENTs: --0A-c E.J ct.t._ Lok Lt.. i'3Z 1..... 0.p Lerse" Pvee'eblc . ga l A. /A Ott) Fltt-7 ,LI A1C-Ki 7...". ( 0 .- I c ' ) Art.% S C"'.-.4,.4 S- <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 and Regulations, and all applicable California State Laws. <br />Signed x <br />1-orc, rint Name AAArS atli-itAr..-- ' <br /> <br />Title/Company e ito 6 (0%-.51 <br />Date 91'11 )1)5 <br /> <br />DEPARTMENT USE ONLY <br />3ITE MAP IN UNIT IV FILE, ADDRESS: <br />NORK PLAN DATED: <br />‘pplication Accepted By <br />3rout Inspection By <br />)estruction Inspection By <br />;OMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE RMIT / SERVICE . <br />,5o 1 k91 6? ((21 91 / OV IA/ SR# to3 /,,Fxy <br />Section <br />.q.31) CA-P44-t4se ,C7; za-ric-4er <br />,P It <br />Date <br />Date <br />Date Issued (;71 Afea..Jalrggt <br />77 Final Inspection BY: "7777bate /7/..144 <br />:-57 / WC -WAIVER 9/30/02 C-57 Letter of Authorization to sign permit