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WELL. PERMIT APPLICATION FORM SITE <br /> C; �VEU TION <br /> AMITIG <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT A <br /> MAR 1 7 2003 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIROWJIENT HEALTH <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 PERMIT!SERVICES (209) 468-3449 <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 2 arcel#Assessor's/f 7-07y-97 <br /> 3Ll L/flco�y S1/t'E�% Cross Street fit/- 69,4�r&A City Jf0e_h70�v Zip--IS 6 <br /> 2�N Z�h? <br /> PROPERTY Owner 1)2 c <br /> Address i1 q,20 S VAII D.1 Al) City Zip 93;4 Phone# $ 7 S,f7 <br /> LASL flt/J/Z/Lj 1, Address 26 1- 7rtGG C�1jGLG�City Nip� Lic#1j:�OPhone# y ds/ <br /> C-57 Contractor � <br /> 1f a <br /> Consultant/Sub Contractor Sr! ]y s`�� /�� Address /32L A/ Phone# `���/Z. <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> X NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL#/tI W-2-a.2-a.`Other: ' Grout Specifications: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> d 4AONITORING •HOLLOW STEM DIA.OF BOREHOLE_—MULTIPLE CASINGS?0 YES *140 WELL CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_5(=% 4) TYPE OF CASING: 0 STEEL A-PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ?/ TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes X�o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: GE/4E-Nr G�� <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 3j/ 100OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? if YES,list specifications here): <br /> 'COMMENTS: <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 ha a prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc R s and Regulations, and all applicable California State Laws. 1 , C <br /> Signed x Title/Compan L ru. 4oi c6c <br /> Print Name (7� til f��'t Date <br /> DEPARTMENT USE ONLY J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Sly L,,/� <br /> WORK PLAN DATED: .¢ARIL_ 1-2--12002- <br /> Application Accepted By (G' Date Issued si'/ C>�l7 Z Area <br /> Grout Inspection By f_ J, �.•n;n Datef"7 Final Inspection By +.+. .+_ Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35_0 ( All All1. g (aZ 310 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />