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04/24/2001 08:41 2094683433 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) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applirabon Is hereby made to San Joaquin County for a Permit to construct and/or instal the work described. This application is made in compliance with San <br /> Joaquin County Development Titte,Chapter 9-1115.3 and the Standards of San Jo quin County Public Health Services,Environmental Health Division. <br /> ((�� (// //,'_� //////������y����y��������nnnnnn Assessor' <br /> WELL Location / �// / 2�" Cross Snntreet , / City l�/L'r K/�L Zip Parcel# ' '_Co <br /> PROPEIZTYOwners� Ckon Address (.�l.Fl� �JuM ��P; f jJ7 Phone# <br /> /�� / ` city �/-� <br /> CS7 Contraclo { /�7t Address IJ ) Cit(y. `ZiPQ�.�.Uc;16 ' 7Phonet(. )3/3 SAO <br /> Consulnnt!Suh.Cpaea/ctnorL( Address I 6 City j9 �UTA Phone 1JJ421I'�–2-'I— <br /> GIS Coordinates:X�l.4Sa'DU Yf�_,7ownshiP LN Range G� Sedon zo <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> SOIL BORING# _3 Q OVER-BORE <br /> U WELL# Q PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: CiTf!`'ll�k'm Gdaf6e - 4–AV%'KOBE <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES (]NO WEt1 CASING DIA:_ <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER, <br /> - <br /> a VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> Q AIR SPARGE &PUSH POINT GROUT SEAL PUMPED p Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING U HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER:_ U OTHER APPROX.BORING DEPTH SCJ U BOLTED TRAFFIC BOX or U 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 la/tions, a d all applicable California State Laws. // G <br /> Signed x 6_ O Title/Compan�/p /(/ <br /> /"!L.*cL9Pi/ <br /> Pnnt Name larr a ����pf� <br /> a /n DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> Application Accepted BY ° l V D to Issued <br /> Grout Inspection By Date nal Inspection By Data <br /> Destruction Inspection Date <br /> COMMENTSICONDRION . <br /> ACCDUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMf FDEC117,K� RE BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> _Z , C� (� I Q 002-�- <br /> C-57_ WC WAIVER_ C-57 Letter of Author z ion t ign permit_Encroachment doc_ 9/27/00 <br />