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FILE COPY <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> SEP 2 0 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH VSERVICES MITIGATION <br /> o ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ER1'r,`i�S�l�'rlE 5 ALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permft 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,Environnwial Health Division. <br /> WELL Location <br /> ri <br /> 6 t en"'e Cross Street //City S c� Grr Zip 4.r;r, l# <br /> ParceAssessor <br /> s. <br /> PROPERTY Owner�i�ta�n l�fa �i�f Address7�{ Lrh /n �'10 - City . Zip Y5.�7 1hone#.2 94017// <br /> C-57 Contractdress .d City ' t14V14 Zip f4 t c#7A!V?VPhone#W 7 j?2V 16W <br /> Consultant F6r�-her eal;or�CS�eM Gia. ,', Address Q City��i�ic#Sl.?BSl �A m <br /> Phone# GC�'S� <br /> GIS Coordinates:X Y Township ;Z/1/ Range_A X Section Al <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below). <br /> D SOIL BORING# �$17VER-BOREWElL#JJ1Gv! �) ��, Lv fjjcs.Sf�6�Ja10 RESSURE GROU <br /> E -Other <br /> rout Specifications: <br /> COMMENTS: /Jl� f MG.Io G� — ace Lc.I 07Lo2 f'Y![r, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?1)YES D NO WELL CASING DIA <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> i <br /> D OTHER:_- n OTHER APPROX BORING DEPTH D BOLTED TRAFFIC BOX or D 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinas, Rule d Regulations,and all applicable California State Laws. <br /> Signed xTitwcompany _ (i• <br /> Print Name GAP L_ �,rr.�h� Date <br /> //DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: CEJ Tis <br /> WORK PLAN DATED: 7- Z �'U <br /> Application Accepted By Date Issued 91—zw / Area Q� <br /> Grout Inspection By Date Final Inspection Date <br /> Destruction Inspection By pate <br /> COMMENTS I CONDITIONS: limp <br /> F <br /> ACCOUNTING ONLY: AID!# <br /> EAGN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3%2--1 �D�' S3 S� -� RS 2 z <br /> r-si7 wr. -U/ATVPD r-Fi7 I o*tor of Antlinri7ntinn to einn horrnit Pnrrnnrhrnonf rinr G/971nn <br /> - h <br />