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01/19/2001 16:05 20946834"'7 FIFTH FLOOR PAGE 02 <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 /> pplication 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 /> oaquin County Development Title,Chapter 9.1115-3 and the Standards of San Joacuin County Public Health Services.Environmental Health Division. <br /> Assessor's <br /> BELL <br /> BELL Location /Df714 Crass Street /&Nn9 Clry Zip q5Z S Parcel# <br /> p .t-tZu/u Ldsa Addy <br /> 'ROPERTY Owner fsfRLrY /1[�j�p�-t.�.41� Address/�/O 45 /54ViLrOc! A/I.CiMS•zr..XiOn� ZIp��Phone#gSa1 `/68-�ct`b <br /> 0 <br /> :-57Contractor lt�,T /4t2!60?7" Address 3233 F,rzGE<<-fii'&Q Ciryrl�c�4 Zp`I� Lic#SSY57`lPhone# 9 - G38-7z76 <br /> �{� " '¢�C'A� Phone# 9/6Sd�-oyr� <br /> :onsultant/Qvb- cotradyr SE'GO/L Address 30/79 O.� ALO '7 City co•irJdiq Lic# ,.p <br /> AS Coordinates:X ,Y ,Tawnshlp � Range �� Section 1 <br /> YORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) 0 DESTRUCTION Q(hoose type ORE low) <br /> Q SOIL BORING# ` _ Q PRESSURE GROUT <br /> WELL# INk i <br /> Other. Grout Specifications: <br /> ;OMMENTS: <br /> rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE &" MULTIPLE CASINGS?Q YES )KNo WELL CASING DIA: Zvi <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS$t/f qd TYPE OF CASING: Q STEEL *PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 40 TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes )�No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: G?T Calf..✓ <br /> Q OTHER: Q <br /> OTHER APPROX BORING DEPTH G.3 r 4OLTED TRAFFIC BOX or []STOVEPIPE <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 10atl <br /> County Ordinances, ules Ind Regulations, and all applicable California State/Laws. /�J� <br /> n Tltie/Company t �i l —5"'fi�0� G" <br /> Signed x 3�7 G <br /> CZIi�/T /7�i�'h -Date,� <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: lI ioton <br /> Dara <br /> Application Accepted By <br /> Grout Insperdlon By <br /> _�`_Date Z O Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE cODFS FEE INFO AMOUNT REMn7ED CHECK# REC-D BY DATE PERMIT/SERVICE REQUEST s INVOICE <br /> 3sp� g�j• oc7 1\� 3 Ibp ooz( �� ) <br /> C-57_ WC—WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />