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04/24/2001 08:41 20946�9433 FIFTH FLOOR • PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 466-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 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 De+ lopm//e//nt Title'./Chapter 9-11115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> --VVVV7��aKyree/p�� .►qG �fCiIy J�IOCKtBn"Z.ip �2 Assess <br /> ,or'sWELL Location City'22;.zZipX02 Parcel# �2/ <br /> S%7,0-Oo/ <br /> PROPERTY Owner Phone# <br /> C-57 Contractor Cityy4ih'1¢LTrp4.Z UcteA(kLPhoe# S 2/ -S <br /> Lm <br /> acity��cS „/cfucu Phoner6�d qs6-2GcoConsultant rL-ArU Address <br /> / <br /> GIS Coordinates:K SSD .Y U� ,Township /A/ Range 6L% Section �� <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING(CPT.GEOPROSE,HYOROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION(choose type below) <br /> $SOIL BORING X Z n OVER-BORE <br /> Q WELL# n PRESSURE GROUT <br /> -Other: Grout SpecifinUans: <br /> COMMENTS: GPTZ I>`UkO PL)A)CH $ ¢'MLO&[Q.B _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING o HOLLOW STEM DIA.OF BOREHOLE Z MULTIPLE CASINGS?n YES U NO WELL CASING DIA:_ <br /> 0 EXTRACTION n AIR HAMMEMRIVEN CASING THICKNESS TYPE OF CASING: n STEEL n PVC n OTHER: <br /> a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS p HOSE <br /> p AIR SPARGE O'USH POINT GROUT SEAL PUMPED ayes S No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS! AleayUSiy,Gr -n'�jya � � <br /> n OTHER: RA <br /> _ n OTHER APPROX.BORING DEPTH n BOLTED TFFIC OX or �STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 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 Ordinances, Rules and Regulations, and all applicable California State Laws. J // I <br /> StgnedxyV � e.//�,y„_/_'__ �,.�' Title/Company 7�� 2C.f /�'Ld.. 44E✓/(i�4(iJ l'6yt <br /> Pnnt Name VY 0 !'/P.x+ ( lr 2ti /la 1, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> 1 h <br /> Application Accepted By v /1. Date Issued ©(� Area <br /> pecti <br /> Grout Inspection By Date F�nal Inson By Data <br /> Destruction Inspection Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID <br /> PIECODESFEEINFO AMOpUNT R.EMITTED CHECK E �ryBY GATE�j PERMIT/SERVIC7E REQUEST#1 INVOICE <br /> loI 0 . WI-S 1' /t! / 'ACL (J <br /> C-57_ WC WAIVER_ C-57 Letter of Autho iz ion t i n permit_Encroachment doc__ 9/27/00 <br />