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i <br /> 03/13/2001 16:21 2094683 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MAR 15 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> VIR( UMEP "j 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> FcR1AT0 <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 TIDe,Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> }=RF.?1�.1r Assessor's <br /> WELL Location q5 -k I;- 14Aa.L40 Cross Street LIP-0 City LAMP Zip Parcel# 1932.10'O? <br /> F24NtiN uwq7FfiGNLI� 21K1'48Z'll-i-► <br /> PROPERTY Owner Cr9-1\10 rsLK.J RTotl- LWI? Address °lso`F S• NA[-LA0 CityLAMP Zlp Phone# <br /> C-57Contractor(rRV-VV Address � S0 N'DvJE. 9-8 CityMAUx,*y12ZIpQySS Lidl6 D Phone# 925-313-SStb'>) <br /> Consultant/Sub Contractor lAm-sw <br /> ,c AcDT R-t�K Address 3 W• LA¢Rfl�ofriOCity S"3�a�w u�# Phonoa 9oS-$0.4-I -z L1 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO BE PERFORMED: Sorb <br /> EW W L,/IBORING(CPT. EOPR ,HYDROPUNCH,HAND-AUGER,OTHER-) t]DESTRUCTION(choose type below) <br /> thillq.J S`sw-- n SOIL BORING# I]OVER-BORE L <br /> ',WELL# `3 ESSURE GROUT <br /> R6%-,.-6r i"FF. <br /> 'Other, Grout Specifications: <br /> COMMENT$: 3 >J� Mtn, a W�u S ,I A?QeOj 40 ID' so;l va4+✓ hTT,�t�T s <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �iOLLOW STEM DIA.OFBOREHOLE Byy MULTIPLE CASINGS?DYES�XNO WELL CASING DIA!2 I <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEELXPVC n OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL PREMIE TYPE TO BE USED: 0 AUGERS >10SE <br /> 11 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED:*'POes n No (NOTE: MAXIMUM FREE-FALL <br /> 0 DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: Cb a fi fi -'a t m �r— SDIJ ' E ^ I S 30 <br /> 0 OTHER!_n OTHER APPROX.BORING DEPTH S'i BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ri5 (if YES,list specifications here): <br /> -COMMENTS: v.rt.11 iA = 32 i6l = 02 3(, =t3D ID''C� 'tar' , <br /> _ to °IU' v �xh 3 t <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR ACHME T PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance With San Joaquin <br /> County Ordinances,Rules and Regulations, and all applicable California State Laws. <br /> Signed _ "" r`Y... Tale/Company S0.• T¢V'z w (>1;.{T.SyIS'C /I.1'Ati� ALPPAUrA <br /> Print Name AV\V--5� wGLLS Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By 94kDale Issued Area <br /> Grout Inspection By VDate Final Inspection By Date <br /> Destruction Inspection By j Dat <br /> COMMENTS I CONDITIONS: a&AA jl� lyw91-cl kAZit- u) '�>l 04- ?PkI <br /> ACCOUNTING ONLY: AID# a-AICPv ISO IMS <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK RRECO BV 9AIJ PERMIT/SERVICE REWEST A INVOICE <br /> Q <br /> C-57_ WC_WAIVER_ C-57 Letter of Auth dtion to i t Encroachment doc_ 9/27/00 <br /> f81'31I <br />