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• <br />RE EP EV) <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />WELL PERMIT APPLICATION FORM <br />AUG 2 4 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />ENVIRONMENT FiLALTH (209) 468-3449 <br />PERMIT/SERVICES <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, Chap r 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />Li &ea/4 Cross Street 7-41 OE_ 51:city -rc:,(Mk_\ Zip Parcel# WELL Location 2308 J. <br />PROPERTY Owner Ci+si err. ,511401 Address 44S' i'd • Ell-NbetosLaCity 57-0c4Mdzipi7 Phone# 75?-3500 <br />C-57 Contractoreer---P2- l'A't Address 23 66 Wibit.vaibtCity 157 -0641d Zipg_251Licttin 2Z68Phone# {16 6-57/2_ <br />Consultant / Sub Contractor ,i/-1-1 I Lk _ auc . Address i Z713 P4-IDDLI ak ugitY LON Lice762. Phone#36-630/ 50 <br />''." W <br />GIS Coordinates: A) 37°5-a , 473 ,yi.o/z- i 'V 7 , 437 ,Township Range Section <br />WORK TO BE PERFORMED: <br />[KEW WELL / BORING ( CPT, GEOPROBE,HYOPUNCH, HAD-AUGER, OTHER*) <br />0 SOIL BORING <br />WELL # *03" <br />O DESTRUCTION (choose type below) <br />0 OVER-BORE <br />I] PRESSURE GROUT <br />*Other: <br /> <br />COMMENTS: <br /> <br />UNIT IV <br />offle6 <br />ORIGINAL <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />[KONITORING 114OLLOW STEM DIA. OF BOREHOLE //3 ts MULTIPLE CASINGS? 114-S a NO WELL CASING DIA: Z <br />[1 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS,A4 40 TYPE OF CASING: 0 STEEL G•14C 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3,5' TREMIE TYPE TO BE USED: 0 AUGERS trrosE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: tiles a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />1:1 SOIL BORING a HAND AUGER APPROX. BORING DEPTH )90 I 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />a OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? Li c. ( if YES, list specifications here): <br />4 pi Lt /4 670 W. Z-4-- 3 E-- t A.) T1-!E- S ; DP Le , A 1_1cl C, 10 .5-)c27 —/ D <br />COMMENTS: C.:)F 14 Li 7-2-2-it2-1-1/, .,, <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub- <br />contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of Califomia." , <br />*_r_10,7... TH NI <br /> <br />I, NSPE TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />...... --- <br />Signed x ‘.. --/ Title/Company 77,if, //7( Z---• ,---27-1 /- A2A-7----A-7--/,f), <br />Print Name Fat/ / w Pi ro A_IPi )J2 C- Date <br />SITE FILE ADDR ORK PLAN DATE: Ark/L. 2.1 SOO/ — <br />Date Issued /0 / Area 1%8 <br />Date 74-4 • 2---- <br />0c,-6v-34014/ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Final Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P / SERVI INVOICE <br />)5(.1 27 lr53 I _C;t* W-24 smt OOZVO6 .__ <br />C-57 exp. WC/waiver C-57 Letter of Authorization to sign permit