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04/24/2001 08:41 2094683 FIFTH FLUOR • 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 /> 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Wes <br /> I 1 Assessor's <br /> WELL Location.sitf Wesf hJ�6 or(- Cross StreetFir+ca{"it city Zip�Pa� l# /37 37 Oa3 <br /> PROPERTY Owners � �� l-1�t/ ��� <br /> 1 Address// ryJCity by 7✓joOc 20L Pnone# <br /> C-57 Contractor \1 Address AbAe �r City'I/{lem- Zjp%gf& Ljc#j&Y(n-Phone# Fr / V 0 <br /> /�'++�� 11 --ovKoT yam,- �r 'tom= // <br /> ConsultantlSullCeeector l.it/eatt r -. Address JAI <br /> Cilyr!¢G.la../�O,IJc# PhanetfO'p <br /> GIS Coordinates:X 6 <3'D ,,Y 42 <br /> Township JA Range O 1011 Section /12 <br /> WORK To BE PERFORMEO: <br /> 0 NEW WELL I BORING(CPT.GEOPROSE,HYOROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> ,SOIL BORING# 3 DOVER-BORE <br /> O WELL# 0 PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING (]HOLLOW STEM DIA,OF BOREHOLE Z MULTIPLE CASINGS?O YES ONO WELLCASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAM ME"RIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER' <br /> - <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED p Yes 'O NNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> S <br /> XSOIL BORING ,HAND AUGER GROUT SPECIFICATION _ /y epi/" 6:e� <br /> a OTHER U OTHER APPROX.BORING DEPTH _ f 0 BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSEO? (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 gulations, and all applicable California State Laws. // <br /> Signed x�/iLsGs.� Eli �r"r Title/Company / IF �/ IL <br /> Print NameC�tLLkt� <br /> _ (t� (p.t VL Date b Q/p� <br /> DEPARTMENT USE ONLY —' <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> � r /4 j <br /> Application Accepted By \' u V Date Issued I� r `to Area <br /> Grout Inspeodon By Date b Final Inspection By Data <br /> Destruction Inspector.4 r r ate <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMTfTED CHECK# YEGIN Bl( DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> Z� �' I X !1/ Z' r,, <br /> C-57_ WC WAIVER_ C-57 Letter of Auth izati t sign permit—Encroachment doc,_ 9/27/00 <br />