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I F <br /> WELL PE�xMIT APPLICATION FORTE <br /> CE Nlkn <br /> _ � DD .,,� ATS O N <br /> I. `SAN JOAQUIN COUNTY <br /> JUN 19 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> IENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> P (209) 468-3449 �1U <br /> ERM(T]SEOV�CES PM �'�� �� <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> IApplication is hereby made to San Joaquin County for a permit to construct and/or install the warts described This appiicabon Es made in compliance with San <br /> Joaquin County Devell�opppment Title,Chapter 9-//1115 3 and the Standards qf San Joaquin County EmAronmentai Health Department C� <br /> WELL Location Ids C�l;ir� 1rYyt',Ily�crossstr et IFG�� C+ty S�'0, Kion .Tip 95x0 moors <br /> PROPERTY Owner V fi �,�S o Address 'I yQs + city J( 2✓1 Tip 9S�zPhone#Za5 Y1? 5.50 y <br /> C-57 Contractor 5 0f- dj Illj Address 3(632- 00,*r_ Cr're.&. citya` zip9 15;-7y� �� S/o Phan 9t 635- b 4 <br /> IConsultant/Sub Crntr 4 CjE - Addrers_ C5 3 7 544 w R� City $Tqc l C,Uc*6 on7.� Phone# � b <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> EW WELL/BORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER.OTHER-) DESTRUCTION(choose type below) <br /> SOIL.BORING# lI OVER-BORE <br /> WELL# KE - 1]PRESSURE GROUT <br /> Other Graut Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS y <br /> MONITORING 1OLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS'? ULT14LEVELI p WELL CASING DIA cZ , <br /> a EXTRACTION 1]AIR HAMMERIDRIVEN CASING THICKNESS�` n0y)[ TYPE OF CASING U STEEL KPVC BOTHER <br /> j] OR Q MUD RO'T'ARY DEPTH OF GROUT SEAL_ 5��� TREm E TYPE TO BE USED []AUGERS *0SE <br /> If] PARGE i Ozane B PUSH POINT GROUT SEAL PUMPED -A�Y g No (NOTE_ MAXIMUM E LE-PALL DEPTH IS 30') <br /> 0 SOIL BORING I]HAND ALGER GROUT SPECIFICATIONS TI E <br /> o OTHER a OTHER APPROX BCRINGDEPTH ��5' T�DLTEI]TRAFFIC 5CX cr 1]STOVE PIPE <br /> C,ONDUCTOR ING PRO SEDC (tf YES,list spe�sications here) <br /> COMMENTS c JG �R fl �V Q M <br />' NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> r CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Lhereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> aunty Orcginances, Rules and Regulations, and all applicable Caldo+rr>lia state Laws. <br />�Signed x --I��' Titled/Company <br /> rint Name JCl <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE.ADDRESS: r `�/ C4.0 P <br /> WORK PLANDATED: <br /> plication Accepted BY ADate Issued 7 F-0--5 Area_ <br /> ut Inspection By Date Final Inspection By Date � 11 <br /> estrus ion Inspection By Date <br /> OMMENTS I GONDITIONS <br /> UNTING ONLY AID# <br /> PE CODES FEE INF=O AMOUNT REMITTED CHECK# RECM BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> -57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment' clot 8/29102 <br /> AP <br />