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11/14/2000 17: 05 2094683433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> W ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> \� (209) 468-3449 <br /> \ <br /> NON-REFIINPABLE PERMrT EXPIRES 1 YEAR FROM DATE ISSUED <br /> q/ppliction is hereby made to San Joaquin County for a permit to construct an install the work described. This application is made in compliance with San <br /> Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Asssessosalth Drvision. <br /> 3 ' of Som ft /off i .`. ross Street ���/ v City 5�06j � Zip ��j�' Parcel# ! n v�-yy <br /> WELL Location ,�� C <br /> Address 3)-?If �,v - City Sdo��fov Zip 5 Phone#1 <br /> PROPERTYOwnerNfi 6P5�iv <br /> CpefgSy7 Lic# xPhon 771� n! <br /> C-57 Contractor i ryP <br /> Consultant/Sub Contractor-Ef S ���v,/ovro>7 � Tw: Address /�� 'r �/✓ Cityv fv Uc1t qZ0 Phon 4"i' S'g "�°�� <br /> GIS Coordinates:X <br /> Y ownship Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER') ll OVER-BORE <br /> Q SOIL BORING# 0 PRESSURE GROUT <br /> (]WELL!! <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRU ION SPECIFICATIONS <br /> Q MONITORING o HOLLOW STEM DIA.OF BOR HOLE -,1^[- L- MULTIPLE CASINGS?13Y-ES ANO W ELL CASING DIA: <br /> �EXTRACTION a AIR HAMMER/DRIVEN CASING THI(,,KNESS^ All-)- TYPE OF CASING: 0 STEEL 0 PVC n OTHER:� <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS p HOSE <br /> n AIR SPARGE ''PUSH POINT GROUTS PUMPED: p Yes 4No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPE IFICATIONS:Ce.H r Lovzlaite �+ <br /> Q OTHER: OTHER APPROX.BORING DEPTH YC rw�- n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTO CASING PROPOSED? AI-1,1 (if YES,list Specifications here): <br /> -COMMENTS: SC, I �, ,;� .� ire. G <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKIN13 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi es, Rules and Regulations, and all applicable California State Laws. <br /> TRIe/Company �° Gr / �iS <br /> Signe _ <br /> Date <br /> Print Name 6 k � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> �n.v� Date IssuedArea <br /> Application Accepted By Date <br /> Grout Inspection Sy Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK V RECD BY DATE PERMIT!SERVICE REQUEST/ INVOICE <br /> C-57 WC -WAIVER C-57 Letter of uthorization to sign permit Encroachment doc 9/27/00 <br />