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11/30/2000 15: 221 2094683433 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 /> 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 D/evello/epJm/e�nnt Title,Chapter 9.11and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> 7�// r -PerskirYa Ave—fivCross Street- �Z Assessor's <br /> WELL Location 22--rr AA 11,�.. ����cgqit��y lip Parcel# /!O-22©'{'1 <br /> PROPERTY Owner FIIII42At Address2ZZgAI1� wy Cityya Zip hang# <br /> C-57 ContractokJl.fbuy= T gddressZA1O P&xy.& ftyf Cite-�"_��` <br /> y„�ygNy�,Zip945?1Lic#07bs92-I Phone# C9j9a5 5- o 7 (Cl <br /> 2 0yZ <br /> Consultant/Sub Contractor ET/C. E/lC)n /v1�_P,ddress 1y aCitv�(,rt /{'tic#A-NA7 PhoneYF 477-791`! <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK To BE PERFORMED: <br /> ANEW WELL/BORING(CPT,GEOPROBE,HYDROPUN�H,HAND-AUGER,OTHER-) 1]DESTRUCTION(choose type below) <br /> ,SOIL BORING# 4 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> `Other: Grout Speclflrations: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: N/A <br /> 13 EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS 14A TYPE OF CASING: []STEEL [/PVC []OTHER- N/A <br /> p VAPOR 9 MUD ROTARY DEPTH OF GROUT SEAL IIIA TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> '¢SOIL BORING 0 HAND AUGER . GROUT SPECIFICATIONS: ,.v <br /> 0 OTHER' 3COTHER APPROX.BORING DEPTH ILI 44r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSEO? (iFYES,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 OrdinanceeS, Rules n Regulations, and all applicable California State Laws. � <br /> Signed x ..�[— moi" GF�L[9By Title/Company -:5: i .� Gro 9�5 /L <br /> Print Name ^4 CLQ^ /C_ G . �� �ers• 5 9-+�L_ Date <br /> DEPARTMENT USE ONLY ^ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED/: <br /> Application Accepted Date Issued /ZlI S OO Areay/z, <br /> Grout Inspection By Oa to Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS]CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACM <br /> PE CODES FEE INFO AMOUNT REM ED CHECK# RECO BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAPVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/CC <br />