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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 /> NONREFUNDABLE 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 Semicas,Environmental Health Division. <br /> 7' / /os` ' / /, "' /. r „ Assessor's <br /> WELL Location .?D W I W�C1Pir ,.wv, cross <br /> nStreet /rn��C. Ln �((CI /M- TipOslo2 Parcel#/97-.r7-0-I <br /> PROPERTY Owner Ne beK.ryg� lPolkte/Y Addresl;Vr CObr�te/CP.]r• CitySloa. W Zip SOZ Phone# <br /> C-57 Contractor bre Address SO t+.1 Cityya4loB2 7Up�Uc# 07%one# 3/3Smo <br /> / zo Ko/l Consultant/%ub.enhaClor Gnu 10, �i • �. Address 9 / 2/6 CitySa c# Phonet�e�-2600 <br /> — V / / <br /> OIS Coordinates:X " <br /> 6 .S� ,Y0 I ISI,Township Z/V Range b Section O <br /> WORK TO BE PERFORMS <br /> Q NEW WELLI BORING CPT GEOPROS UNCH HAND-AUGER,OTHER') Q DESTRUCTION(choose type below) <br /> OILS ORING# Q OVER-BORE <br /> QWELL# ••''-- �^� Trersr..rrQ�FFIES&LN2E GROUT <br /> 'Other: Grout Specifications:/I/'%nn.f' �-�N Lir eTi.�t <br /> COMMENTS: C P-r 71ZOR0 Pct NL H d Citvo W,eO RL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> R MONITORING Q HOLLOW STEM DIA.OF BOREHOLES MULTIPLE CASINGS?Q YES n NO WELL CASING DIA: <br /> Q EXTRACTION n AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING: n STEEL n PVC n OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL S'01 TREMIE TYPE TO BE USED: Q AUGERS &HOSE <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED Q Y,,e//s Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS!/t e'xe 64Wv est" C!S/h2 Tf err wl a Pie <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH s a? Q BOLTED TRAFFIC BOX or Q 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 Law/ �/�s. <br /> Signed /N �C�-G 2�s�b TitlelCompany�ror ea A awa C!e10>2 <br /> Pnnt Name Q.frelt C�lu.wtbe!'(cai,1.L Date Ili -£�-O/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By rl - \ `"-` �� Date Issued 4 1 Area <br /> Grout Inspection ByI J4 NJ, DateZ21 mal Inspection By Oale <br /> Destruction Inspectn By Data <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACU <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 145-�- a I I SRA OU <br /> C-57_ WC--WAIVER.- C-57 Letter of Autho izat' sign permit—Encroachment doc__-__ 9/27/00 <br />