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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE fI101ES� 1�/1LJ([�,ITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS� UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA. 95202 7 2004 <br /> (209) 468-3449 ENVIRONMENT HEALfil <br /> PERMRjSERVICES <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 /> Assessor's <br /> '/ <br /> WELL Location S/0 1• y7AH10LJA SFEELT- Cross Street City_ST6GKrb.O Zip 95'A0�1 Parcel# /,3 -.00-Dy <br /> PROPERTYOwner CS/,L Address_ 00 GC44C•) SvOAB City_46NAL LtGN Zip ZO&A Phone#SY"-JS/-*'/ZO <br /> C-57 Contractor %RFs Address//950.yoUlL4 RE✓_ &cz CityWip 9En7 Lic#NLSLk Phone#ft-W3- <br /> Consultant/Sub <br /> 3-Consultant/Sub Contractor L'eU21M 69TH IIW,IAAddress_!88/Xat)P-A&remLs- City $m[,r T4V Lic# Phone#,?0%-,735r-OSl6' <br /> Sur f4Y ,,II <br /> GIS Coordinates:X ,Y ,Township y Norm Range jr EAST Section ,2 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOL BORING# )O TwrAL p OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: pV,,Zy S.xtn Du 2te ItMcwJMr7WS f7PeA( DrSe. A PAcuigoS 552 asrrrs Sts 477--,ter-Mb W441S i <br /> srrc GOLArloA.) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE .7W MULTIPLE CASINGS?0 YES N�40 WELL CASING DIA:_AI _ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: []STEEL I]PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 9Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH */LNJILUTS 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: Q Bd121U6•5 %e .94',ee-s $ &Rr.l)bs TI,' 40'Se-s <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 Ordina e R le d egulations, and all applicable California State Laws. <br /> Signed a� L ,Y _Title/Company .✓r)oi2 �Pf7/T /ECrra>atoGlfy l�G <br /> Print Na a re rfE Lr.J� L�oyL£. I Date .Vec. lT2oG� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 5 16 <br /> WORK PLAN DATED: Ib (/ <br /> Application Accepted By Date Issued 1Z 6 �'�_ Area f7 —2-- <br /> Grout Inspection By Date Final Inspection By Date)a- <br /> Destruction Inspection By Date <br /> COMMENTS/CON DITIONSi <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> aq 41 17 0 0 5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Autharization to sign permit_ Encroachment doc_ 9/27/00 <br />