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02/23/2001 10 05 2094683433 <br /> FI✓=TN FLODR <br /> jTAGE �2 � <br /> WELL PERMIT APPLICATION FORM SITEZ/ <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E.Weber, Third Floor, Stockton, CA-, 95202 v1'Y� <br /> e _,_woed <br /> (209) 468-3449 Q t, <br /> HOPI-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> kpphcation is hereby made to San Joaquart County for a permit to construct andror tnstafl the work descnbed Thks oppiscatfon»rnade In compliance voth San <br /> toagvin County Development Tide Cttiapter 9.1115 3 and the Standards of San Joaquin County Public Health Serv,ces,Environmental Health Div+ston <br /> Assesw1116 <br /> �NELLLocatlon �y41 E1v All(„ � R52a�1 i'areel#� r'st�3-��{ Z <br /> �" 1 Cross Street G qty Zip r��.. c� �{ <br /> PROPERTY Ownet rGV� Address /k/6 A664K ,� City .] p_�.7��Phone# a `545 <br /> CZ7 C4mtrw= Kb4 DI"It'NAddrassSSC> �, �* City, �+ i TiA N��I Lic41 OQ ° F'honelF <br /> Consultant/Sub Contractor �►� Address ���fcas�, Ciey 11 Llc3 ?hortztlt =55'I �, <br /> GIS Coordinates X Y .Township Range Section <br /> W,Q13K TO IRE PERFONED <br /> NEW WELL f BORING(CPT GEOPROSE HY'OROPU14CM HAND-AUGER,OTHER-) 17 DESTRUCTION(choose type below) <br /> (I SOIL BORING a 1)OVER-50142 - <br /> ,�WELL# U! 13 PRESSURE GROUT <br /> 'Other � Grout SpeaEcahcns <br /> COMMEN'T'S ' <br /> TYPE OF WELL WSTALLATION TYPE CON!STRUC'F)ON SPEC1tIC6ngNS <br /> XMONiTORING XHOLLOW STEM Ct(A OF$OREHOLE__d!�_MULTIPLE CASiNGSl Q YESXNO W ELL CASING DIA l{ <br /> jft-MACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NcV TYPE OF CASING p MEL XP VC (]OTHER <br /> IMIRPOR 11 MUD ROTARY DEPTH OF GROUT SEALZls TREMIE TYPE TO BE USED D AUGERS )*OSE <br /> p AIR SPARGE B PUSH POINT GROUT SEAL IDUMPEDYes ti Na (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 17 SOIL 8MNG 0 HAND AUGER GROUT SP ECIFICATtp air rdcl <br /> 0 OTHI R n OTHER APPROX.BORING DEPTH, 2�" — - OLTED TRAFFIC BOX at (}STOVE PIPE <br /> CONDUCTOR CASIATG PROPOSED?�D(11 YES,fist specifications hers) <br /> •COMMV"S• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS Its ADVANCE FOR ALL. REQUIRED INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina s uI !-iz utatiarts, and all applicable California State laws. 1 <br /> Signecl x Tite/Compan <br /> Print Name n cc Date d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: vtb J4 6" � <br /> WORK PLAN DATED: 7r -0 <br /> Applicabon Accepted By Date Issued �! �++ «.� Area <br /> Groul Inspection By Date F%nal Inspecbon By ,- - � � Date___ <br /> Qestnettlon lnspedlon 8y Date <br /> COMMENTS 1 CONDITIONS- "• +' 7- <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CRECK S1 REC'D BY DATE PERMIT I SERVICE REOUW A INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc— 9/27100 <br /> FEB 23 '01 l 0 00 <br /> - 26946e3433 PAGE 002 <br />