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12/ 21 / 2001 15 : 51 209- 51 25 MODESTO ATC ' PAGE 04 <br />� i <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PMS-EHD) <br /> 304 E . Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468 =3449 <br /> NCAI,REFUNQA6LE PERMIT EXPIRES 1 YEAR FR M DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This aces, Environmental <br /> is made In compliance with San <br /> Joaquin County Development Title, Chapter 9.1 115.3 and the Standards of San Joaquin County Public Health Services. Environme AssessorsDiviaion�o� _D� > <br /> WELL Location <br /> (01,4 N - J\ - Cross Street (Dzxr' STI, ' City $4&�Vj%c�� Zlp Parcel# J <br /> Ownern, <br /> PROPERTY. F4Jv�� AddreIy3 RU f� Mtn. [, f . City $�Dt�'r zip '11 ZI,+r Phone# � is -3 � '� <br /> 1 '� _ Address PoD , a0K 33b Cityfe�b dd4u Zip g4T74Lic#1I06!P1 Phone#��' T3'"t ' �O <br /> CST Contractor UJ C' "I •d IIA -- <br /> Consultant iSub Contractor <br /> Arm ACS I. Addresa IliG Gty Aaclllk�0 Uc#Phona# S� UZl - - <br /> OIS Coordinates: x <br /> y , Township Range Section <br /> WORK T FORMED; DESTRUCTION (choose type beloyt) <br /> EW WELL / BORING ( CPT, GEOPROBE, HYD ROPUNCH, HAND-AUGER, OTHER') U U OVER-BORE <br /> U SOIL aORING # PRESSURE GROUT <br /> WELL # <br /> *Other. Grout Speafloatlona: <br /> COMMENTS; <br /> WISH <br /> TYPE OF WELL INSTALLATION TYPE rn. c�UCTION SPECIFICATIONS <br /> U MONITORING kilOLLOW STEM DIA. OF BOREHOLE I5.. MULTIPLE CASINGS? U YES �f40 WELL CASING DIA:? <br /> U <br /> EXTRACTION UAIft HAMMER/DRIVEN CASING THICKNESS C4\ <br /> 4p TYPE OF CASING; U STEEL JrI D OTHER: <br /> VAPOR U MUD ROTARY DEPTH OF GROUT SEAL L)a� _ TREWE TYPE TO BE USED: �WAUGSRS U HOSE <br /> AIR SPARGE U PUSH POINT GROUT 5EAL PUMPED: U Yea g'NO (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> U SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: OLTED TRAFFIC BOX or p STOvE PIPE <br /> U OTHER:.Q OTHER APPROX, BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? 06 ( if YES, list specifications here): <br /> •COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 4R WORKING HOURS IN ADVANCE FOIE 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, R�u/�es and eg fatiane, and all applicable California State Laws. <br /> Signed x � � " <br /> V Mr\ 'rtle/Company <br /> r p ti xut, eti\ pate I Z n I <br /> Print Name DEPARTMENT <br /> tnr�/ USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Ie / too Area <br /> Application Accepted By ''' ° Date Issued <br /> Grout Inspection By <br /> ate Final Inspection By Date <br /> Destruction Inspection y Date <br /> COMMENTS f CONDITIONS: �f <br /> ACCOUNTING ONLY; AID# v <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D DY DATE PER f SERVICE REQUE INVOICE <br /> 2 \ 2- I <br /> ment doc� 9/ 27/00 <br /> C-57,� WC.-,WAIVER. C- 57 Letter of Autho 1 Vo sign permit_ Encroach <br />