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11130/2000 15: 21 209468343? FIFTH FLOOR "LEyI� P <br /> - OY <br /> WELL PERMIT APPLICATION FORM SITE <br /> APP Z001 MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r: UNIT 1V <br /> LTN ENVIR©NMENTAL HEALTH DIVISION {PH5-EHC) <br /> 304 E- Weber, Third Floor, Stockton, CA., 9520.2 <br /> (209) 468-3449 ,W> <br /> �r <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,.pplicatien 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 /> loaquin County Development ��Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division, <br /> II nd L Assessor's <br /> NELL Location f S. e I QQ'�u17 Cross Street 2,` #:: � CityIS. - 7p Zip Parcel# <br /> 'ROPERTYOwnar lam_ J"jS�b, n - AddressN25/V. c1 Dve4/j6 5Y City �n Zip 45�/_Phone# <br /> -57 Corltractcrrl;) a.tJ1� Address <br /> /� w City lsflt ZipQLLic#`?Ij`T�_Phonel; �3cro <br /> consultant/Sub Contractor ELIC LiI fyLi�Address��tyu-rdlo :�LY_Cit '+c# t}O Phone# <br /> GIs Co mates:X Y`J Township Range , Section <br /> - <br /> r <br /> TO PE Fn E _ lr2t ��c> �1`Q131 14'05 S- C DfGID <br /> J NEW WELL./BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ;DESTRUCTION (choose type below) <br /> n SOIL BORING# ROVER-SORE <br /> WELL# (7 PRESSURE GROUT <br /> 'Other: Gr ut Sp ( ` tions: <br /> �OMMENTS: [ _4 S fl -_ -C. -- -- <br /> rYP5 QF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .MONITORING Q HOLLOW STEM DIA_OF BOREHOLE MULTIPLE CASINGS?[I YES [INO WELL CASING DIA: <br /> I EXTRACTION Q AIR HAMMER/DRtVEN CASING THICKNESS TYPE OF CASING: []STEEL U PVC I]OTHER:, <br /> ]VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO SE USED: 0 AUGERS Q HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED, 0 Yes 13 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .1 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> j OTHER: 0 OTHER APPRON. BORING DEPTH ©SOL-rED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rulesa d Regulations, and all applicable California State Laws. <br /> 3ignedx C­I� 6- Title/Company. /p 'ri <br /> print Nam- ohm �C.'/ S Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��� S �)e-tA� <br /> WORK PLAN DATED: -yooa <br /> >pplieat on acceptedBy Date Issued f ! — a 6 <br /> Srout Inspecflan By Date Final Inspection 8y ; e� <br /> Destruction Inspection By Date 4tC <br /> :OMMENTS/CONDITIONS: Y� r ��� J- o/ <br /> ACCOUNTING ONLY: AID# I� <br /> PE CODES FEE INFO AMOUNT REMMYED CHECK* REG'D BY DATE PERMrr I SERVICE=REQUEST# INVOICE <br /> 5oz. L-0! <br /> C-57 WC---WAIVER C-57 Letter of Authorization to sign permit Encroachment dac 9/27/00 <br />