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09/28/2001 12 ti 13 � 2994683433r ' FIFTH FLOOR PAGE 135 <br /> I <br /> WELL PERMIT APPLICATION FORM sIT� <br /> Sr P 2 Q 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SEIRVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> SE i k GELAN 304 E. Weber, Third Floor, Stockton, CA., 95202 . <br /> Ft,1a; �1 s/���'J`iL E (209) 488-3449rI/ b <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a perrnrt to Construct and/or install the work described TI)is 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, Env,ronmental Health Division <br /> E Assessors <br /> WELL Locationaa_Idar,,, 'L ienu2 Crass Street/ l r/�� /JCRy .Si �c'_.al1l Zip ft.�7 Parcel# I <br /> PROPERTY Owner Zedto/n f J� t-h'fr' Address 7 LAlr-.4 L'60/0- Crty, Zip !r!r W7 Phone# I 9"P X 7// <br /> I <br /> c-57 Cantractora:!l , Qh'� dress es3 City ' f/i Zip 9YS7 Lic#7/ TlPhone#'71 2V 40 <br /> Consultant r Ger regRor�CJ Cid"&riyv�Glr'Address f3�,f+��.9• Crh/�l�rtac#5138�Phone#SJ�_4q <br /> 60 <br /> GIS Coordinates X-- ,Y TawnsNp N - _Range Section zlf <br /> I <br /> WORK TO BE PERFORMED <br /> C NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") )<DESTRUCTION(choose type below) <br /> 13 SOIL BORING# V'OVER-BORE <br /> XWELL# u <br /> y 4V.1, tat, ,��12't_ 1 Ihk+S'Vm4"1a %Q-PRESSURE GVOU <br /> 'Other 0 Grout Specifications .-f,M C40*V% <br /> COMMENTS ,—Mw lXli-fe rAA4.10 Gews- lrjt-a2 IVc­3 f Mes, / I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING [I HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS p YES p NO 1NELL CASING DIA <br /> *ACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASTING p STEEL p PVC D�OTHER <br /> OR p MUD ROTARY DEPTH OF GROUT SEAL 'PREMIE TYPE TO BE USED Q AUGERS p HOSE <br /> B AIR SPARGE p PUSH POINT GROUT SEAL PUMPED p Yes p No (NOTE IMAXIMILI i FREE-FALLI DEPTH IS 30) <br /> 0 SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS_ ,_ <br /> Q OTHER t7 OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? -- I <br /> (if YES,list specrfications here) <br /> 'COMMENTS <br /> MOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCRdACHMENT 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 don in accordance with San Joaquin <br /> County Ordina s, Rullesand Regulations, and all applicable California State Laws l <br /> Signed x TitlelCompany <br /> Print Name C ,� t�c.�-J� Date <br /> DEPARTMENT USE ONLY <br /> SITZ=MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 7" 417 U <br /> Application Accepted By _ d <br /> Date Issue ` / Are <br /> Grout Inspection By Date Final Inspection 8 D ems, <br /> Destruction Inspection By Date Q <br /> ENTS I CONDITIONS E <br /> ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D 13Y DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 4019-F.5 �F ?U Z <br /> t �i7 mle _WATVP0 r-;;71 ottar of Aittknrvrnt�nrs to Linn normit Fnrrnnrhmont rtnr 0177/nn <br /> _ i <br />