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04/08/2002 12:24 209e' 1413 FIFTH FLOOR PAGE 03 <br /> �9 WELL PERMIT APPLICATION FORM SITE <br /> N <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 9-1115.3 and.the Standards of San Joaquin County Public Health Services,Environmental Health SD`vision. <br /> �'U-K 3� � N�rc Street — _cI C�orti<�� zip q>�(- Paroel# tr-l-o`30-�3 <br /> WELL Location Sir. Cross Street tY <br /> �`�`►1 Ns;l�t I`1RS,•E Ci S�V��o:,; Zlp 20e Phoneff��C1`q�943'561? <br /> PROPERTY Owner �"� SEStytr F� Address tY <br /> �b 5�;� <br /> C-57 Contractor V S0.uN_�`C Addres__ �\\Q �GAf15 �'r'E sritY� LfR;�•� 2ipl-145&&Llc# c5)1`I Phone''�'�lU <br /> SutE �AecJ;�� LickI 57141 Phone#��ko�Sq -•3Cr)0 <br /> Consultant/Sub Contractor VRS CcrFcrn�r� Address_5D') 1- 7 'cZ:—! r'-. City <br /> GIS Coordinates:X ,YTownship Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> ANEW WELL/BORING(CPT,GEOPP.09E.HYDROPUNCH,HAND-AUGER,OTHER') U 1)OVER-BORE <br /> 0 SOIL BORING 9 0 PRESSURE GROUT' <br /> �j;WELtf: MN—til <br /> *Other: Grout Specifications: <br /> COI�iMENTS: _ � 5 06St� ct� <br /> TYPE OF WKLL 11lSTn.LLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n <br /> `�'�1nNITOR.ING 'HOLLOW STEM DIA.OF BOREHOLE 12" MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA <br /> i i h.IR.HnMMER1DRIVEN CASING THICKNESSScN 140 TYPE OF CASING: Q STEEL XPVC Q OTHER: <br /> n v.n,POP, 11 NWO R01APY DEPTH OF GROUT SEAL 7REMIE TYPE TO BE USED: D AUGERS �g1i0SE <br /> Il A.IR SPARGE i`.FU.;H POINT GROUT SEAL PUMPED: Q Yes �'�10 (NOTE: MAXIMUM SFR L DEPTH IS 1� SA) '� <br /> p Soil.BORING 11 HAND AUGER GROUT SPECIFICATIONS: i'' <br /> n OTHF?: iI.C THEP. APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or l7 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: FO^ Atm <U ^ t=1 tom,; tJZ3 1 <br /> 0 VT <br /> _ F -1 L.x-> � �t.r�t~ .., � v�'�:5;✓� -s�r�a OSF41t.\CC— �t►4t��v=• F�c.�s� O.��t s+..c.H��c.Tss2 <br /> 10.rE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> I INrr IJ ItiSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby rcrtiry that I have prepared this application and that the work will be done in accordance with San Joaquln <br /> err• =, T�.� 1F c anri Regulations, and all applicable California State Laws. <br /> Sinned X TtfelCompany <br /> f QA^qe <br /> Print Namc__ '`^ t^ k ���- �— Date <br /> D PARTMENT-USE ONLY <br /> SITE MAR.IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> i ' <br /> Area <br /> oats Issued 6 Z l-L g C l b I <br /> Appllcation'Accepted By <br /> Grout Inso�ction By Date 02- Final Inspection By Date_1_ <br /> Des'iuction Inspection By.. Date <br /> COMMFNTS!CONDITIONS.__, G1� « fl <br /> ACCOUNTING ONLY: I` AID# <br /> PF-COD ES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT/SERVICE REQUEST 1t INVOICE <br /> 8 <br /> Cr57 WAIVE . C-57 Letter of authorization to sign permit Encroachment doc 9/27/00 <br />