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09!25%2000 14: 35 20946636/3 FIFTH FLOOP, ;= 02 <br /> S11110-4 - <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> JAN 19 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> :VIRON*--I4l r!E4LiN (209) 468-3449 <br /> � 'yyffISERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .pplication i r made to San Joaquin County for a permit to construct and/or install the work described. This application is made In wrrpliance nd4 San <br /> oaquln County Development Title,Chapter 9-11t5.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. l� <br /> _ Assessor's <br /> VELL Location-}OJW S-c kKIk� R� Cross Street_City :eu- 2ip 53 6P,rrelc 209- zyo-2 (� <br /> 'ROPERTY OwnerOW,?K 4- [&-cc kWcw _Address � 4'�Do W .S��,,,IIQ CityT�-t ZiP9S3gkPnonec2o9-$3k -QL/ �V <br /> 1 / SIZZ64t _ <br /> :-57 Contractor-5P2!rrT�'I,s,n.-� '/^gddres5 Z3(ate tr�J r�;,JsM., 1�'. City AS-�.< Ic�-u..�ip� LL5—L,ca PnoneX Z=7-of 6S <br /> :onsultant,Sub Contractor CSO Id e IrAs 5 r„ Address_lra [Jy'';✓Lcl"JQCiry Q�IClq cu Phone3 510-2341-?0 <br /> ;IS Coordinates.X Y Townshlp. .Rare Section <br /> YORK TO BE PERFORMED- <br /> i NEW WELL r BORING(CPT.GEOPROBE.HYDROPUNCH, HAND-AUGER.OTHER') t]DESTRUCTION(chwse Ape oe:ow) r� <br /> D SOIL BORING f 0 OVER-BORE <br /> (]WELL# 0 PRESSURE GROUT <br /> Other GROUT SPECIFICATION <br /> :OIAM E NI S: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 40NITORING WI�0LLOW STEM DIA.OF BOREHOLE G &A. MULTIPLE CASINGS?0 YES o NO WELL CASING DIA: Z I'- . <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS u^. e.S,:N TYPE OF CASING: p STEEL R4Vr- p OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED- 0 AUGERS OHOSEll-'e <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: G.4es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) �} <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATION J`-'e,,,1- C,OwY,4- <br /> OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or &-6TO1,E PIPE <br /> CONDUCTOR CASING PROPOSED? Ald, (if YES,list specificaeons rera) <br /> ,OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> 'ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> CALL TyE UNIT IV IN$PE TOR 48 WORKING HOURS INADVANCE FOR ALL REQUIRED INSPECTIONS <br /> pnedz f�T/ - G� Title/Company_ ( (o,t�.� t-la�csni / (re (�1� ASsocie.J-y r c. <br /> -int Name I' a"+ 2 , K(24. okc1S Date V1) 0. �O I <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> 3plication Accepted By Date Issued I 2.) e- Area <br /> ,out InspectIon By Date o Final Inspection By Date3� i <br /> astruction Inspection By Date <br /> OMMENTS/(CONDTTIONSI rCit <br /> l — z <br /> ACCOUNTING ONLY. AIDd <br /> f✓�I ��- � 1l( <br /> 1E CODE=SFEE FO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT l SERVICE REOUE ST F INVOICE <br /> X90( A16`1 230 �S OS <br /> C-57 WC/WAIVER_ C-57 Letter of Authorization to Siqn permit_ Encroachment do- 9/:2/OC <br />