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. 04-20-2001 03:40PM FRO I M TO 19168531860 P.04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> APR 3 0 2001 ENVIRONMENTAL HEALTH DIVISION (PMS-EHO) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> &.REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is heraby made to San Joaqu ounty for a permit 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 Semites,Endronmantal Health Division, <br /> /ln <br /> !I /11SO u2�7//"'STAT A Assessor's <br /> WELL Location M010A WBIAYG,I SOL/N'F/00 Cross SheeY:g�y�,'—ma Uty /pAc7 zip N/1 Parcel# <br /> PROPERTYOwner_�pfE��ay nJC- AddreesSy/f� s�4t�•2il>FE.H6CL 2D. city vt/ zip .�B Phone#<yzs-J 7-zo78 <br /> C57 ContractorrI5C11 641r1&4y&Vr Address 399 5&6/11 5 PLArE City 95DS21Ic# °3S�iPhone# z- x S-7� <br /> r PeosPscT � 2a�rX� <br /> Coetsultantl Sub Contractor T/�FFAJ tn1C Address�a3'Vjc rno_n„r'A Udfjjj8 Phone> ±"6J o'5-2-lgop <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> MED: <br /> ANEW WELL/BORING(CPT.GEOPROBE.HYDROPUNC ,HAND-AUGER,OTHER-) x[DESTRUCTION(choose We below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL#_ 11 PRESSURE GROUT <br /> 'Other. Grout Specifications: NEAT Cy-/✓tFnZT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION JEECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE .5 C MULTIPLE CASINGS?0 YES 'O'NO WELL CASING DIA.- <br /> [I <br /> IA0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL _ _ __ _TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE `PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;"OIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: n/6fi7 CSMC.JT <br /> 0 OTHER: ,, n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A10(if YES,list specifications here): <br /> 'COMMENTS:�/E 5/1E �S 62t5seWT L/ AliXLIr- 74, 1/dr�7 L T r SA�r+A"Al( NF 8 O/-, O <br /> Nr� CASINLl- e«aiP n Air) /.1l/1' R,-- Z'JI&e /Eiv/-AJ7 <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,/Rules and <br /> Regulations,and all applicable California State Laws. / <br /> Signed x `�`�- -L_� Tiue/company /1�0;T-C-Tla!/S-7r Ar7a LI4SA(S,1`A/( . <br /> Print Name -' 'Io/li LCr Date s 7 00 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By `-+ ' I ate Issued (/ 3o c6 <br /> ! Area <br /> Grout Impedon By - .1 Date Final Inspection 6y 7,60 Date_ <br /> Destruction In don B <br /> COMMENTS I CONDITIONS:-... <br /> ACCOUNTING ONLY: AID# <br /> rANt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REOUEsr# INVOICE <br /> ZRG OD asmi of? <br /> C-57_ WC--WAIVER— C-57 Letter of Auth i sign p mit_Encroachment doc^ 9/27/00 <br /> TOTAL P.04 <br />