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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) T n <br /> 304 E. Weber, Third Floor, Stockton, CA., 55202 - <br /> (209) 468-3449 SEP 2 2 2003 <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 rnAW WQ&t 91WE46 H <br /> Joaquin C9un p vetopWnntt 3e,Chapter 5-1115.3 and the Standards of San Joaquin County Public Health Services,,Environ`menW"Moxff �IfCES <br /> NELL Location 3 S \�• �� U 0(��a(e St Cross Street CI f000Jn `S2 0`! sess I N. <br /> ty Zip Parcel# I N.5 1 <br /> PROPERTY Owner t Addres'A City } I���zT�r� -+�-,-trarre u 0 71 <br /> QO �J ZSLf toy 1 Lic#�zU90 phone# qk'- _11-1 i41-Oo <br /> C-577 Contractor ��� �c�.;�1:r�. Address � 41b City �,�. Zip9S <br /> onsuttant Sub Contractor �eA\a�",Cn.QTer,hc.�cYlddress ��bj 1 S{ City JkSfO Lac# — Phone#209 5-Z-L I I <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 111 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# OVER-BORE <br /> Ill WELL 3 m V• VIS O PRESSURE GROUT <br /> *Other; Sps-- W Dorno"' k-R 1.- -1-i _ o `Z- Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> /MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES 0 NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC. []OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS 0 HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> - <br /> CONDUCTOR�CASING^PROPOSED? (if YES,list specifications here):�— <br /> `COMMENTS: 1X� yy 1� 1y`\�1^��S 1�°1 -iQ )Q 1 1 Z_ d �0 ' Z1 /V L <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O nc�s, a nd Regulations,and all applicable California State Laws. O h s �` ��-�- <br /> Title/Company C�e o�� e AA �C.��� . c S ••� <br /> Signed x �L <br /> Print Name �a�1r4�� �C' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By C' Date Issued_ N(/V l�i C V�� __ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: U_z�k-b r") <br /> ACCOUNTING ONLY: AID# <br /> �.� P Q.I'/y( a tri <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> CIE # R 'D B DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 50 g r 3 3 <br /> C-57— WC=WAIVER C-57 Letter of Autho a ion t si n ermit—Encroachment doc 9/27/00 <br /> 60 39d8 6001. H13I3 ££b£89b60Z 99:£1; 100Z/8Z/Z0 <br />