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10-24-2000 03:40PM FROM TO <br />RD 1U WELL PERMIT APPLICATION FORM <br />15306760005 P.02 <br />OCT 2 4 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <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 9-111115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location �oSD_. ask rTCmolt 1T. Cross StreeI //^ Ci <br />Assessor <br />'l <br />lc( ty S% fo�1 zip Parcel# 153-Yi)-D3 <br />PROPERTY Owner%e 4n .IVO�&"Address.701 S Ain 4- , _City A�hftA Zip �O Phone# do4- q3(• O�D <br />G57 Contractor 00� t�tn� I l /f cess J�S� 1`�y t'^ 2cl CitKR (005 6 Y4 <br />Zi 5 y y 7 3 Y j <br />p� Lic�PhoneN_� 00 <br />II <br />Consultant/ Sub ContractorJ�-• �AVirD11,/>•(.Address? 330�gt11�T►�� CF�f.r ci Al f��bl( Lic# Phone#530-6k-2bkZ <br />g568Z <br />GIs Coordinates: x Y Township Range _ Section <br />WORK TO BE PERFORMED; <br />,NEW WELL / BORING (CRT. GEOPROBE. HYDROPUNCH, HAND -AUGER. OTHER-) DESTRUCTION (choose type below) <br />o SOIL BO IN # rl OVER -BORE <br />1.1NELL1 - W W -I d� ?RESSURE GROUT <br />'Other: it Graut S ecifcations: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />&HOLLOW STEM <br />0 EXTRACTION <br />n AIR HAMMER/DRIVEN <br />0 VAPOR <br />p MUD ROTARY <br />0 AIR SPARGE <br />p PUSH POINT <br />U SOIL BORING 0 HAND AUGER <br />Q OTHER - _a OTHER <br />d <br />CONSTRUCTION SPECIFICATIONS `J1 <br />DIA. OF BOREHOLE—'3� MULTIPLE CASINGS? Q YES 1,NO WELL CASING DIA: Z <br />CASING THICKNES . '(D TYPE OF CASING: rl STEEL 1<7VC i] OTHER: <br />DEPTH OF GROUT SEALWTREMIE TYPE TO BE USED: � E SE t <br />GROUT SEAL PUMPED: )Yes No (N�OOTE: MAXIMUM FREE -FALL TH <br />GROUT SPECIFICATIONS: i�fRy1�XM71 <br />APPROX. BORING DEPTH Venwk(J, `J�SOLTED TRAFFIC BOX or p STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Yt0 (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, Rules and Regulations, and all applicable California StateLaws. <br />Signedx GJW" nc4 Title/Company Pmej Gfbt0S.:,+- S �i1y��Ji1i►�•� <br />Print Name SLb4 19. '� +r A Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, A DRESS:_ -2-0S 0 ase <br />WORK PLAN DATED:_ I o �t U Z <br />Application Accepted By of h Date lssued3/0y Area 17 <br />Grout Inspection By l{��.� Date 3 v Finaf Inspection By._ Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITI <br />ACCOUNTING ONLY: <br />AIDS <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />11 <br />3Yo <br />37,03 <br />C-57_ WC_ -WAIVER,_,,,,,,_, C-57 Letter of Authorization to sign permit_ Encroachment doc 9/27/00 <br />TOTAL P.02 <br />