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02/13/2001 08:36 209468?? ^q3 FIFTH FLOOR t <br /> "'- PAGE 02 <br /> WELL PERMIT APPLICATION FORM . SITE <br /> TION ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202I <br /> (209)468.3449 CC6 • C�5 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct andlor install the work described. This application is made In compliance with San <br /> Joaquin County Development Title.Chapter 9-1175.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Divislon. <br /> WELL Locallo /Iq{/�r- .t•,.z��,�„,,,�c' <br /> ,/ekrwCross Street Assessor's arcel# <br /> � � � 1 Y6�3 <br /> PROPERLY Owner ( ta, rf\ `}nr I<_r%,^nAtldress_��I-I�t I1 City Tip 13 TI_�Z Phone# 1(�, 9. ,5 < <br /> C•57 Contractor L`1” 1- i-C'S-i+L`Address -q5-Q 'kJQ ('.'{ Cityr :r �lY -ZiP i$yLic#rii:Yt7 Phon@#9�S-.-3i:3�5 + <br /> Consultant/Sub Contractor Cl-12!11-lll_L Addresstix bl"CJ I�}�^I. �}i�f- Cltyt-��1�:�QrN.�Lic# Phona� P)10 LSI Z M� eAr <br /> GIs Coordinates:X .Y ,Township Range Section <br /> x; <br /> WERK TO BE OORMED: <br /> _W WELL ING W\GEOPROBE,HYDROPUNCH,HAND-AUGM OTHER')/ � 0 DESTRUCTION(Cho <br /> ose type below) <br /> 0 SOIL BORING - <br /> 0 OVER-BORE <br /> n WELL# I / 13 PRESSURE GROUT , <br /> 'Other; Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?N YES C NO WELL CASING DIP:i <br /> 1 a EXTRACTION C AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC 0 OTHER <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C AUGERS CHOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: X'Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: '' <br /> ()OTHER: OTHER G I APPROX.BORING DEPTH 1150" a BOLTED TRAFFIC BOX or,l 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED'�(if YES,list specifications here): <br /> *COMMENTS: <br /> iI <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 herebAinaes, <br /> have prepared this application and that the work will be done in accordance With';San Joaquin <br /> Countules an Reg Fati ns,and all applicable California St to Laws. <br /> signedx TitlelCompany �`� I (ZiL PAntNa ) <br /> DEPARTMENT USE ONLY I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 1 <br /> Appurahon Accepted By Q Lo F ST��'� Data lsauea `1 ��3 � G I �. Area <br /> Grout Inspection By�D21e Final Inspection By II Date �- <br /> 1 DesWtdon Inspection By Da "- `- <br /> i COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FArW <br /> PE CODES I FEE INFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 5 I1 ��.DL> g0oD(AUUv Orn t-- <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit Encroachment doe_ 9/27/00 <br /> it <br />