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08/29/01 WED 14:51 FAX 415 8'.2 9475 PES ENVIRONMENTAL [a 002 <br /> WELL PERMIT APPLICATION FORM SITE <br /> - � <br /> SAN JOAQUtN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-E-HD) <br /> l 6 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3"9 <br /> NON-11 PERMrT EXPIRlzS 1 YEAR FROM DATF ISSUED <br /> Application is hereby made to San Joaquin Count for <br /> a p the S ndards of San Joa4u�'�n Counntty�Public Heatth Services,Environmental Health Dicompliance <br /> on th San <br /> Joaquin County D,e� 'rye��,p3 S. Q{!`pOv� LL� AS3al# 177-020=53 <br /> S <br /> 1YQSSi.-±'J"'�i1�' � � ParoOf# /7 7-DXJ-S 3 <br /> WELL Loattan e _ uIc -Crow Stree <br /> fi 9y/USPhone# <br /> PROPERTY Owner Lln;2ti C'{c /(aAddressd` >iCvepjQ ��S�F� City Lp <br /> 8 bG ��Zp9Sjol_Lic#�$o3jPhonetl�� 5G8- <br /> CS7 Contrador�',f.n.(�cant A-'�IIr��L.-� ,/+ddrers`�3 I,J.(�(lec�a-��... Ci ,�ca..w <br /> v /� IVO✓AA �)1VJCi l.ic�t A9-6a Phon / Pff X4-0 <br /> Consultant/Sub Contractor / �� fr v,ipyv►yi„trtG Address .1- b <br /> G15 Coordinates:X <br /> y awnship Range _SecLon <br /> w0DEST <br /> K TO BE PERFQRMED: RUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,FLAN AUGER,OTHER-) 13 OVERBORE <br /> MOIL BORING fF o PRESSURE GROUT <br /> a WELL 0 Grout Spedflcations. <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL IHSToLLATION TYPE CONSTRU ON SPECIFICATIONS <br /> (j MONITORING HOLLOW STEM DIA-OF BOREHOLE -7 r- R MULTIPLE CASINGS?U YES $'NO WELL CASING DIA:�_ <br /> s <br /> ()EXTRACTION Q AIR HAMMER/DRIVEN CASING THI KNESS_[V�_ <br /> TYPE OF CASING: 0 STEEL 0 PVC n OTHER ►�_ r <br /> []VAPOR Q MUD ROTARY DEPTH OF C ROUT SEAL �0 M TRE1u1fE TYPE TO BE USED (I AUGERS LI HOSE <br /> AIR SPARGE <br /> �gtty-r-Vie- GROUTS PUMPED: 0 Yes ANo (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> _ P „; G rot+�+ <br /> SOIL BORING HAND AUGER GROUT SPE IFICATIONS:.. gOI.TED TRAFFIC BOX of Q STOVE PIPE V <br /> I)OTHER: �1 OTHER APPROX BORING DEPTH 3d w Y � <br /> CONDUCTO CASING PROPOSED? /1r (if YES,list specifications herey. <br /> 'COMMENTS: <br /> c <br /> NOTE: OFFSITE BORINGS REQ IRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKIN13 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 Ordin es, Rules and Regulations,and all applicable California State Laws. <br /> - , TNelCompany If on f .r <br /> Signed x _ <br /> Print Name <br /> f bate 11 l5 <br /> DEP TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> Applintion ACrepted Date Issued Area <br /> 0 <br /> Grout Inspection By 13y DateOZ14 Final Inspection 13y Date i�� <br /> Destruction Inspection By Date i <br /> COMMENT'S 1 CONDRIONS: <br /> ACCOUNTING ONLY: AIS <br /> PERMITI SERVICE REQUEST X INVOICE <br /> PE COOES FEE INFO AMOUNT REMrTTED CHECK# RECD BY DATE <br /> IL 9/27/OC <br /> C-57 W -WAIVER— C-57 Letter of uthorization to sign per it_Encroachment dot <br /> C <br />