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! 12/ 21 / 2001 15 : 51 209 - 579 -- `225 MODESTO ATC PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC 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 PERMITPE_ IR�YEAR FROM DATE ISSUED <br /> Appllcadon Is hereby made to San Joaquln County for a permit to construct andlor Install the work described. This sppllcadcn is made In compliance with San <br /> Joaquin County Development TitleChapte 9.1 115.3 and the <br /> the Standards of 8ar1�Joaquin County Public Health Services. Environmemal Health Division. <br /> WELL Location_ C,pt _ (, ©'L� or ` Crass Street za-4� City 5c+��^ zip P oegsars <br /> PROPERTYOwner FA'T r '""""' ©� Address ' Lr • Clty zip "hone# *9-4=m32A*-a <br /> C•5Y ConlraCor <br /> Vfdx�Ja � , hlly Address PD QOc 33b C44Q\bVtStu �pq`H'+ �tJc#� oo� 4Phone#�� T3*1 - tf3n0 <br /> 1. <br /> '�L <br /> Consultant lSub Contractor AASSN Address tit'} L ;ii - kL.^ A City k.e&Ao Uc# Phone#52 : LZZ( <br /> CIS Coordinates X . Y , Township Range. Seacin <br /> WORK TO F RMED : DESTRUCTION (Choose type bel ) <br /> EW WELL / SORING ( CP] , PROBE, HYDROPUNCH , HAND-AUGER, OTHER') 0 U OVER-BORE <br /> 13 SVEt- R RINLG# PRESSORS GROUT <br /> •Other. Grout Speciticadone: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATION <br /> 0 MONITORING �-IOLLOW STEM DIA. OF BOREHOLE � MULTIPLE CASINGS? 0 YES ,)1ifEO WELL CASING DIA: Z , <br /> a EXTRACTION 1] AIR HAMMERfORIVEN CASING THICKNESS LP TYPE OF CASING: d STEEL Ar46VC U OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 12 'Y�� TREMIE TYPE TO BE USED: gAUGERS a HOSE <br /> AIR SPARGE Il PUSH POINT GROUT SEAL PUMPED: p Yes $'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> II SOIL BORING D HAND AUGER GROUT SPECIFICATIONS; �Atrk <br /> O OTHER:.0 OTHER APPROX, BORING DEPTH x'W 680OLTED TRAFFIC BOX w [) STOVEPIPE <br /> CONDUCTOR CASING PROPOSSO? ( if YES, list specifications here): <br /> 'COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOA ALL REQUIRED INSPECTIONS. <br /> 1 hereby ceRity that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rfu)es and 11RR--e�.g lations, and all applicable California State Laws. <br /> Signed A f'^^ Title/Company <br /> Print Name rt&d a `A AX - Date IZ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : rr/_ <br /> Appllcatlon Accepted By <br /> ' <br /> Inspection "v 0 4 Date Issued A0 o I A. <br /> Grout Inspection By Date 4nkinal Inspectlon By Oats <br /> Oestructloa Inspection B C Date <br /> COMMENTS f CONDITIONS: t <br /> ACCOUNTING ONLY; AID# FACA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK s REC' 9Y DATE PERMIT ! SERVICE REQUEST # INVOICE <br /> 3 .ct 9 . r) c� 2t2 ` z� -`� �( <br /> C-57� WC -WAIVER. C- 57 Letter of Autho Iz o sigri permit_ Encroachment doc. 9/ 27/00 <br />