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04/24/2001 08:41 209463 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 /> Application Is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter&1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location 103 S. �1 N Co�r� S1- cross stn:et city zipz Assessor's <br /> 3 - 00 6 <br /> PROPERTY Ownne "T& v('K Cy O x(e Address Cr�'f NccM City _Zp�Phone# <br /> C-57 ContractorinY Qr�S,LLLr t, Address l {J City/ry WbV'z=lGi Zip yS _1Jd&&O_Phcne# <br /> Consultant!Sub-6e/n6vekrl_�L,�.` Ariz Address CityP�C4J0,."P.. U'#F Ptlone Z�4L�26W <br /> GIS Coordinates: ,V S-71- ,Township / Range G e! secllon /o <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION(choose type below) <br /> $SOIL BORING# I D OVER-BORE <br /> Q WELL# <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: Grout Specifications' . <br /> S .CO L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a7 YES D NO WELLCASING DIA:_ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL D PVC D OTHER: <br /> D VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> DAIRSPARGE PUSH POINT GROUT SEAL PUMPEDr],Y,ee/s DNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> KSOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS:NCot- (ionae" Au.T.1-9 —7xn4(.,rr� <br /> D OTHER: D OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D 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 Orrdiinf nces, Rules and { �jr7�y lations and all applicable California State Laws. <br /> Signed x fZ' ��// Title/Company_ <br /> Print Name_/41aee4i . C2 Q Lv1 /o ✓(a et Date 6 8�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By ` `l/ 'J Date Issued C e� Area <br /> Grout Inspection By Date Rnal Inspection By Data <br /> Destructon InspeGian Data <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAQV <br /> PE CODES FEE INFO AMOUNT REM"ED CHECK# REC'D BY I DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authgf iz ,I n o sign permit_Encroachment doc____. 9/27/00 <br />