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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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Vplication 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 />(I(1 e V- Cross Street 1)01j1S City ,SiDtittO VI Zip <br />pAasrceseistitso/312.......40 LACi <br />NELL Locationt) (AP It, <br />Address ILP onaci City SaOrfaillel WZip11531t Phone# (111055*--no3 'ROPERTY Owner Co0 WWII II I ify27 <br />-57 Contractor ea OOdan 11.a 30 r Address 1 OviliG CAW) City 11 91 CA No <br />. Zip Lic# ig v Phone#6/01,3/1 11 7. S <br />onsultant /Sub Contractor5ISWe I hfrryi AddressiVa Lic# Phone#M100(0-0L/W <br />."...' <br />NORK TO BE PERFORMED: (75 <br />I NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) C5." <br />a SOIL BORING #, a OVER-BORE <br />[j WELL # 411,i)-s ( cil ti .fli) a PRESSURE GROUT <br />Grout Specifications: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? U YES :RNO WELL CASING DIA: <br />IP3 EMIE TYPE TO BE USED: U AUGERS a HOSE <br />Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />IVO I te/ <br />APPROX. BORING DEPTH Y1 110' )(BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED .10 .(,if YES, list specifications here): <br />COMMENTS: OW/ Cite') 011-1-1-0 tijta e flit Mfg_ 01 )0 r<11+ SCralA i tj <br />re- i I hcks, <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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />/YORK PLAN DATED: 6 -Site 1144.11 rf -) (Z) toe 40€ stbc-, fk-e"---tav <br />Area 997 <br />Date <br />:OMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# c e rit <br />PE CODES FEE INFO AMOUNT REMITTED CHECK X REC'D BY DATE PERMIT! ICE REQUEST # INVOICE <br />.n"gq - t pc-- 0 i SI 0 6 -74, 41./z--- 0 3/03 R# eo o <br />:-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br />3IS Coordinates: X 30.01-140 Y -124 .M6-3S2. , Township Range Section <br />Other: <br />:OMMENTS: <br />IYPE OF WELL INSTALLATION TYPE <br />MONITORING HOLLOW STEM <br />] EXTRACTION ,XAIR HAMMER/DRIVEN <br />] VAPOR a MUD ROTARY <br />] AIR SPARGE fl PUSH POINT <br />] SOIL BORING 0 HAND AUGER <br />]OTHER: I] OTHER <br />CASING THICKNESS(tkii ,40 TYPE 0 CASING: STEEL )i,.PVC OTHER: <br />lU <br />DEPTH OF GROUT SEAL / vlk <br />GROUT SEAL PUMPED: <br />GROUT SPECIFICATIO <br />rn xpproX, <br />ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Title/Company -Alta ql.ALVIt10-155(0e- klanctfi coal, <br />Signed x 1611441// *Id pt.( <br />' <br /> Jjit <br />rint Name pt 5%1 r E,LA 0 rutA Date ICI. HP (Os' r <br />DEPARTMENT USE ONLY <br />Vplication Accepted By <br />3rout Inspection By <br />)estruction Inspection By <br /> Date /- <br />Date <br />Date Issued <br />Final Inspection By