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11/15/2001 14:02 2094683433 FIFTH FLOOR _ �0� <br /> WELL PERMIT APPLICATION FORM SITE <br /> 'i' I f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGAfI <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 93202 02 ,2L In Pti is: 18 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> glicauon is hereby made to San Joaquin County for a permit o construct and/or Install the work described. This application is made in compliance with San <br /> aquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> / 11 Assessors <br /> ELL Location 210q CQ16646 I1,n I' �I V� Crosss Street City,}{O�ckhO/h� Zlp Parcel#123-OND-?.�7 <br /> ROPERTY OwnerLyleLz �„'/1fI„�=e�i �1. Addressl.0- B& 5004, �1CQitY.A�i1,XlfIIOtLZip 4S8 Phone#012C• <br /> -S/ConVactorWAddress{1_ 2�j�.r' ia�Ci4'-CACI.—Zip Lic#�i4579 Phone#91(o-�n�e <br /> onsultant/Sub Conlrado I f c VAr /�/� Address IZ rt HMp! ,.' r City_ Mea-4eLLic#(og0134_Phone#'2S - <br /> L <br /> iS Coordinates:X ,Y ,Township Range Section <br /> IORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) 13 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# - 11 OVER-BORE <br /> WELL NSP,- � SP-A -A SP- 0 PRESSURE GROUT <br /> Other: Grout Specifications; <br /> :OMMENTS: <br /> Yl OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING III HOLLOW STEM DIA.OF BOREHOLE B rr MULTIPLE CASINGS?.D YES #NO WELL CASING DIA: Z� <br /> EXTRACTION 13 AIR HAMMER/DRIVEN CASING THICKNES YYPE OF CASING: 0 STEEL�14PVC 0 OTHER: <br /> j VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TRENIIE TYPE TO BE USED: [IAUGERS 0 HOSE <br /> )AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING []HAND AUGER GROUT SPECIFICATIONS:A)PA't /p <br /> ]OTHER: n OTHER APPROX.BORING DEP TH�!W,4 \� BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTS CASING PROPOSED? tJa- (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 l have prepared this application and that the work will be done in accordance With San Joaquin <br /> County Ordinan es, 2ulleess�/land �egtslati l and all applicable California State Laws/. <br /> Si9nedX� �✓ [��t hl \( TidelCompany /Fd'd/,l c. /"AYML -t- //✓elf�1.'F��•swr iwtw..� <br /> Print Namee /�r�/M'd A. ���M7t� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C:�t-jz),a <br /> WORK PLAN DATED: la�` �' D� <br /> zlx- <br /> Application Accepted By �- Date Issued -( ' Id' Area <br /> Grout Inspection Ely— _ _ Date Final Inspection B} lI Date /Q” 't7z- <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D BY GATE PERMIT/SERVICE REQUE T8 INVOICE <br /> Jvo a-i lv-io• R4D a/ <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment dor_ 9/27/00 <br />