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09/25/2001 07:44 20946924 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> c. ENVIRONMENTAL HEALTH DIVISION (PHS EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 5202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXP RES 1 YEAR FROM DATE SSUED <br /> Application is hereby mane to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquln County Development Toe,Chapter 9-1115.3 and the Standards of San Joaquin County Public Heall Services,Environmental Health Division. <br /> r5 L / I FQs-� Assessor's <br /> WELL Location I5DT >• NARL�AO Cross Street�Clty (, Zip '157-31 Parcel# 193ZIoo3 <br /> �R6-NI.N L 55 _ <br /> PROPERTY Owner (rR AIS �LYV�ITOL Address QS Ot{ 140-C+40 City�R• t ZP152-1 Phone#Z04 -q EJ*2�"IZ.1 <br /> /� tINAm-710f,? <br /> C-57 Contractor yRE-U•(r V'i+-rLLItX/Address 950 Hewes R-d. ,City t-0"i' Zip T5;S Lic#65b4� Phone#1a2S-313-Sdt�p <br /> Consultant/Sub Contractor_I'��y� t �L'7R11.1•>, Address3 Y'I ' L"ltLRtLt-IO��Oclry SA to Lkn�2tz Phone#VCS-B Rq-y22y <br /> GIS Coordinates:X ,Y ,Township Range Secu'on <br /> WORK TO BE PERFORMED: <br /> ;;);NEW WELL/BORING(CPT,GEOPROBE HYDROPUNCH HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> ;•gSOIL BORIN # '- Q OVER-BORE <br /> 0WELL# 0 PRESSURE GROUT <br /> 'Other: Grout SpeclllcaUons w R T1.1rL <br /> COMMENTS: Z ,r0 o.•, JZ.a (t�St. 7 S e.•. , <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N 'l• <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE, J!I MULTIPLE CASIN S'7 0 YES 0 NO WELL CASING DIA-- <br /> a <br /> IA:o EXTRACTIONgAIR HAMME RIVEN CASING THICKNESS TYPE OF C ING: a STEEL 0 PVC [I OTHER: <br /> aVAPOR /0 MUD ROTARY DEPTH OF GROUT SEAL TREMI TYPE TO BE USED: D AUGERS O HOSE <br /> a AIR SPARGE o PUSH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> o OTHER: D OTHER APPROX.BORING DEPTH uP ti IZ,S r o OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING Payr POSED? (If ES,Ilsl speclUcatlons hare): <br /> 1 <br /> *COMMENTS: �tNtn • • Y'Q.. � <br /> rn •n 1 r7st-o �11aT''L l, 6t In <br /> NOTE: UOFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ILL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be don in accordance with San Joaquin <br /> County Or ' ces, Rules and Re lotions, and all applicable California State Lis s. <br /> { V-03SX)T �f6a$Tr1Sl <br /> Signed \� �' T101company S1Al E. ALDRItA. 1r7fr <br /> sv (� —2 <br /> Print Name_ ��vi.7 W i't�>,.LCj ate l D) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> �oplication Accepted By D to Issued Aron <br /> /Grout Inspection By ate d �nal Inspection By Eb Date <br /> Destruction Inspecio By le / <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECK M EC' Y I DATE PERMIT SERVICE REOUEST# INVOICE <br /> 0 !' lb Z 0 Z.-\ j <br /> -57_ WC_WAIVER_ C-57 Letter of Auth iZoti 541n pe mit_Encroachment doc_ 9/27/00 <br />