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02/13/2001 08:36 2094FO3433 • , FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM . SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County 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 31115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> q� Assessor's <br /> WELLLocation Fo.� wext li 4 r .h cross street lh mk Az city Shx,�C�.rn zip Parcel# <br /> i )o � d ess City Zip Phone# <br /> PROPERTY Owner C'Q(� � vn,� Trnm�:<� <br /> C•57 Contractor Address City. Zip Lic# Phone# <br /> Consultant lSub Contractor 4T W!i) Address City �, ' uc# Phone# S l.L,,V 7 jt? cv�.2iZl <br /> GIS Coordinates:X .Y ,Township Range - Section <br /> WIE PERFORMED: <br /> , <br /> rMEILL BORING(OPT,GEOPROSE,HYDROPUNCH.HAND-AUGER.OTHER-) 11 DESTRUCMON:(Chaose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> I WELL# 0 PRESSURE GRQUT \ <br /> -Other- C'"^n,\>v ;n <br /> ac 1mP�\� Grout Speriflcatlons:,rp,HN N,+}_ ^C�>r�t'�4 (t,,d l-ti 1ti2�n bjyn4:7.•<�u..) <br /> COMMENTS: <br /> r i <br /> TYP <br /> E OF WELL INSTALLATION TYPE ``CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM (1',iDr�.t�'L'•' IA.OF BOREHOLE � ,• MULTIPLE CASINGS7[I YES OJO WELL CASING DIA: <br /> o EXTRACTION 0 AI HAMME JDR1VEN CASING THICKNESS E OF CASING: 0 STEEL WgVC l 0 OTHER: <br /> 0 VAPOR p UD ROTARY (1 DEPTH OF GROAT SEAL 130ITREMIE TYPE TO BE USED: 0 AUGERS ,HOSE <br /> 0 AIR SPARGE 0 PUSH POINT well) GROUT SEAL PUMPED: Wes 17 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH J50 <br /> OLTEO TRAFFIC BOX .or p STOVE PIPE <br /> r, CONDUCTOR CASING PROPOSED? (if YES,Ilst specifications here): <br /> 'COMMENTS:�'✓tiu5N (cx�J L [ Ws t L r0 [s0` w4 94 JSTE L Cir ox.1VL Cwt/-(s is ,tn Ica N t zv`. <br /> I ,PT &yrziNr,-, 0A/ 91j3 C76/IZ.Q'%KP 1 ('+Vt•� l II <br /> NOTE: OFFSITE BORINGS REQUIRE ACCO ENCROACHMENT PERMITS. <br /> CALL THE UNrr IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> it <br /> I hereb a fy that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> Cour Ord( antes,Rules an lations,and all applicable California State Laws. N' <br /> Signed x TitlelCompany / <br /> Print Name /� -rK Dated/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: CCD <br /> WORK PLAN DATED! EJ - 1 C-> G' <br /> ;t i+ <br /> Application Accepted By Yl. 3' 'tom Date Issued / J I 'I Area <br /> Grout Inspedlan By Date Final Inspection By Date <br /> Destruction Inspection By Date � <br /> COMMENTS!CONorrIONS: <br /> ACCOUNTING ONLY; AIDS <br /> PECOOES FEEINFO AMOUNT REMnTEO CHECK# REC'06Y DATE PERMrr If SERVICE REQUEST# INVOICE <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />