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WELL PERMIT APPLICATION FORM <br />JUN 2 4 2004 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRUNNIENI' HEALTH ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />PPRMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />`-y) N,Uo-'�(209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />btt — PA'U-�� <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 />�,� �l r- I ` / Assessor's <br />WELL Location�y w�� V�� `7 - oss Street +ry le" 0 /city I. -Any <br />, / Zip � �•33; Parcel# ) 5 5 210 •-Z3 <br />PROPERTY Owner 2rY In {Gv�O \\ �Y'J SS a -QJ L Address 22� 000�Ic L({N� City � ', �/ Zip / ��o Phone# /04 C' <br />C-57 Contractor Wax);Ajcr t V ' Address 53 0 RrVer T a•) City -0 X F5 } , Zip Iy157(Lic#71��i Phone# (76 7) 3�/ - 73�6 <br />Consultant / Sub Contractor0G(` twt� �L�.w ( Address 347 k+ ��U� (� City c° -'sic# Phone#l��-((d <br />GIS Coordinates: X AA- 'Y Township IAA Range AA4 Section X14 <br />WORK TO BE PERFORMED: <br />X+ EN WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />OVER -BORE t e <br />IZe -in S it (1r I'►Qn [] SOIL BORING # 0 PRESSURE GROUT <br />'Other: WELL Grout Specifications: <br />COMMENTS: dU"�,� LIn�� 4i I ���; r �vK4 LU i✓�cll is i�I� 1D r<urjzr5 fa�� r H �ledir� <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />) HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING 0 HAND AUGER <br />0 OTHER:_O OTHER <br />'COMMENTS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE (U(/ _ MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: Z C <br />CASING THICKNESS r C� SIL TYPE OF CASING: 0 STEEL 4 PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: i Ax, f �� v <br />APPROX. BORING DEPTH --2( 0 BOLTED TRAFFIC BOX or XSTOVE PIPE <br />CONDUCTOR CASING PROPOSED? l ( if YES, list specifications here): <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, Rule and Regulations, and all applicable California State Laws. <br />Signed — T <br />9 itle/Company <br />Print Name I,J�� � � �`�� Date C2 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED:41.5-0 <br />Application Accepted By <br />Grout Inspection By_ <br />Destruction Inspection E <br />COMMENTS / CONDITIONS: IV <br />errni 1NT1mr nmi v Ain# <br />1(0s-Oo s.- .z - <br />Date <br />Date Issued /erZ S -0 <br />Final Inspection By <br />C-57 V WC III( C-57 Letter of Authorization to sign permit Enc,: oc 9/27/0 <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P E REQ # <br />INVOICE <br />PE CODES <br />0 <br />C-57 V WC III( C-57 Letter of Authorization to sign permit Enc,: oc 9/27/0 <br />