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I <br /> 12/ 21 / 2001 15 : 51 209-57 "' 25 MODESTO ATC PAGE 02 <br /> I <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> j 304 E . Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468=3449 <br /> NOM REFUN ABLER IRE91 YEAR EROM OATS 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 8-1715.3 and the Standards 01 San Joaquin County Public Health Services, Environma AssersoHeal th Di <br /> WELL LOcatlon <br /> Ca i� J\ cro9s Street <br /> Cxtkk S4-, City 4&kI 7Jp Parcel# <br /> PROPERTY Owner �a� �p.�Mt'� Addre99 City `rof. f � ZIp 457J-9 Phone# qSZ - 31ttQ <br /> 34q Ska r 'S plo-t,_ CIty�al 5 r Ip `tSZ5'1 Llc#(#103`665 Phone# 14'Z - 3544? <br /> C.57 Contractor 5[�.n � Aj • Address f. <br /> Consultant / Sub Contractor <br /> ( c Address (•�1�' LeJ✓<- f-n1u.. City okp4 Ac' Lic# Phone# <br /> GIS COoreMetea: X - - -- <br /> Y , Townshlp Range Section <br /> WORK TO HE PERFORMED: h DESTRUCTION (choose type belay) <br /> 'WEW WELL BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND-AUGER, OTHER') a OVERBORE <br /> ,SOIL BORING # n pRe$SURE GROUT <br /> 0 WELL It <br /> Grout SpedBratlona: <br /> 'Other: <br /> COMMENTS: <br /> TYPE DF WELL INSTALLATION TYPE rnNSTRUCTION SPECIFICATION$ <br /> a MONITORING 0 HOLLOW STEM CIA. OF BOREHOLE,!!. MULTIPLE CASINGS7 p YES g4O WELL CASING DIA:_ <br /> q EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASTING: TO BE USED; L7 0 R • <br /> G RSp HOSE <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL Z5 <br /> D AIR SPARGE )OUSH POINT GROUT SEAL PUMPED: p Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS =) <br /> OIL BORING d HAND AUGER GROUT SPECIFICATIONS: <br /> STOVE PIPE <br /> p OTHER: ❑ OTHER APPROX. BORING DEPTH 7.5 p BOLTEC TRAFFIC BOX ar (] <br /> CONDUCTOR CASING PROPOSED? ( it YES, list specifications here): _ <br /> *COMMENTS: <br /> NOTEN. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS . <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR A! L 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, pules an Regulations, and all applicable California <br /> State <br /> Laws. <br /> Signed x <br /> D /t.(�^n! Mile/Companyx7c tCt <br /> Print Name Date <br /> "-' f I]N <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> fir, W Dale 19aued <br /> Application Accepted By DdtO_�_ <br /> Grout Inspection By Date Z final Inspection By <br /> Destruction inspection By Date <br /> COMMENTS ! CONDITIONS: <br /> v ` ( e <br /> ACCOUNTING ONLY: AID# I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # C' Y DATE PERMIT ! SERVICE REQUEST C INVOICE <br /> O p Z 2 200 UC. <br /> C- 7_ WC_WAIVER G57 Letter of Autho z n 0 sign p rmit � Encrdoch Hent doc� 9/ 27/00 <br />