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ORIGINAL <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(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 />RCAlt PIC.C4 , Assessor', <br />City Zip cf5.2,c, <br />.. <br />Parcel# 444017,4; Cross Street Dr- 2-0 <br />,-. A <br /> <br />Address 5.I.De rac., ft—i.,.42 City 5to M31 Zip 752,0 7Phone# 52 -6277 <br />, P,.11P,L37-c; Address 3:233 rtilervic; Rd City(9-cki Zin95-7'f2i.ic#.5i'--/V7hone#Ci/e,/P:g7,276 <br />SITE <br />MITIGATION <br />UNIT IV <br />WELL Location 500 191c ,c-Ic re <br /> <br />PROPERTY Owner 5-t7 Kb. <br />C-57 Contractor .kkiegt <br />Consultant / Sub Contractor <4tAddress üity il)/aCeki ic# (.1-:-.-:;3./81?='hone#.7V-1557,;1 --C <br />, Township Range Section GIS Coordinates: X ,Y <br />WORK TO BE PERFORMED: <br />'QNrEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />&WELL # PA14 - 4,J,J " <br />*Other: <br />COMMENTS: -tAittu 1•4413 <br />0 DESTRUCTION (choose type below) <br />0 OVER-BORE <br />[I PRESSURE GROUT <br />Grout Specifications:j9f <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING *IOLLOW STEM <br />0 EXTRACTION a AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: rtter-Pti t ,f- <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH /055 WBOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 4/o 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 I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules d Regulations, and all applicable California State Laws. <br />'(.1;-eciC5 L Title/Company ,--,V2AX-4-f)-34-1,14-V <br />Print Name <br /> <br />ent Pc41t" Date R -30-61 <br />DEPARTMENT USE ONLY <br /> <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 1/) MULTIPLE CASINGS? 0 YES NO <br />CASING THICKNESS ':(:•/14,4 Wi TYPE OF CASING: 0 S EEL PVC U OTHER: <br />DEPTH OF GROUT SEAL 9 1.86 TREMIE TYPE TO BE USED: U AUGERS <br />WELL CASING DIA: <br />[21 HOSE <br />GROUT SEAL PUMPED: AY 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />Signed x <br />_ a4ce,...€ <br />O / - f eihel A it C13 ,a7V4V-e ‘1411,64.- / <br /> Area 46ey <br />7. 240• 02_ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS! CONDITIONS: <br /> <br />Date Issued <br />Date <br />Date <br /> <br />Final Inspection By <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: /0 <br />ACCOUNTINGONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P T # INVOICE <br />3501 gA.6 oF)? 4/5/3 ae/W- SR# e'6147349 3 <br />C-5 7 WC -WAIVER C-57 Letter of Authorization to sign permit 9/27/00 <br />