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08/02/2000, - 09: 42 2094683433. FIFTH FLOOR ��� COPY <br /> `/ - `. <br /> WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 C) 'v <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �pplieation 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 /> !oaquin County Development Title,Chapter 9-11153 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> NELL Location"I C1 O W� L �S 3 3 L A'ssessor's Q <br /> 1,`old r1 S c^24� Cross Street She City Ah'ie,C A Zip Assessor's <br /> 0 l L- <br /> £O <br /> 'ROPERTYOwner OeA,Oc�S Ga.-1-k'4a , Address t 0 �oX IO '1-Z citymP►_ ri�C� Zip 33(OPhoner <br /> -1'4Jrjqoy <br /> `ytDvL%\\ nAddress 94S71 Lic#s7 ConVaaolVt � <br /> a�9��35-41y' <br /> Phone#_1o'7-'37�- (S <br /> :onsultant/Sub Contractor Address City Lic# Phone# <br /> 31S Coordinates:X ,Y Township Range Section <br /> 1VORK TO BE PERFORMED: <br /> 3 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGE O R-} j)DESTRUCTION(choose type below) <br /> SOIL BORING# �,Gg��PtiAbQ-!C q OVER-BORE <br /> 11 WELL# p PRESSURE GROUT <br /> 'Other: — GROUT SPECIFICATION <br /> OMMENTS: <br /> TYPE OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 0 HOLLOW STEM DIA,OP BOREHOLE MULTIPLE CASINGS?]]YES a NO WELL CASING DIA: <br /> 11 EXTRACTION 13 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL n PVC 0 OTHER;_ <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS ©HOSE <br /> G AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 8 HAND AUGER GROUT SPECIFICATION <br /> []OTHER: 11 OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws,and Rules and Regulations of the San Joaquin County. <br /> CAL HE UNIT ,TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x �-� 1 � TitlelCompany <br /> Print Name „��ho �b lAr��.J Date <br /> SITE MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED I I S— 0 1 <br /> DEPARTMENT USE ONLY AA <br /> Application Accepted By . Date Issued 2 �'� <br /> "D F Area '- <br /> Grout Inspection Sy Date Final Inspection By Date <br /> Destruction Inspectlon By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 35o i SB /222. 2• -bl SR# 0025 <br /> C-57 WC/WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 7/17/00 <br />