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04/1'/?001 15: 11 2094683433 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 /> ApplicaKen is hereby matle to San Joaquin County for a permit to cons,ruet andlor install Ina work described. This application is made in compliance with San <br /> Joaquin County Development Mle,Chapter 0-1115,3 and the Sundards of San Joaquin County Public Health Sar6ces.Environmental Health Division. <br /> I n �� r- r's <br /> WELL Location 1113 SkAvy e4AL� I $}alt/-kh Cross Street F Lwia"& city SiQC,0r— zIp Assesso <br /> 45 ZOS Assellf <br /> PROPERTYOwner ho EmW&L Addrees 1113 SI'A''J YPA, cjry_ o 1(K Zip 452ZS Phone#`164' 9h3! <br /> C-57 contractor FZSean e-wJ. Address 399Slntii`c PIa(+- D;h,1]g1 S r> p9Sl)'iUa#E$1'Pj6`SPhone# 3.3'`'�-ZJ�IS <br /> Consultant/Sub Contractor 4-M Atmtt-e.I,+s Address lit} Lnuu NA,,, "$ City/JI.AkW Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO BE PERFORMED_ <br /> NEW WELL!BORING(CPT. EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below} <br /> OIL BORING# QOVER-BORE <br /> 0 W ELL# 0 PRESSURE GROUT <br /> -Other: Grout Speciflc2tlons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING O HOLLOW STEM DIA OF BOREHOLE 1I-5' MULTIPLE CASINGS?p YES D NO WELL CASING DIA:- <br /> 0 EXTRACTION C AIR HAMMERIPRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPCR C MUD ROTARY DEPTH OF GROUT SEAL 35 � TREMIE TYPE TO BE USED' 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED' 0 yos 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> jj�SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: N-2 `� y-"'r-"I'-' <br /> 0 OTHER: 0 OTHER APPROX.50RING DEPTH 3s, 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list spe lica+ions here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N 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, Ru es and Regulations, and all applicable California�Spta/t�e Laws. <br /> Signed r� /t'�/'^/ � v � Tlwcompany�--STP F'��'t-f"} Mm,.A*,� (A-VL <br /> Pnnt Name �l`tW V Q'`^ 4\" Date 41115101 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: �4 �s 1 ) I) 3 5G <br /> WORK PLAN DATED: r-1 <br /> Application Accepted By Date Issued y /�,��,/ Area <br /> Grout Inspection By C� yy�� A _Late `� 0 Final Irsspec5on BY (A' AI +-� 0a+e <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDS rArm <br /> I I <br /> PE ccoES FEE INFO AMOUNT REMITTED pj �q +<K <br /> CK# RECD BY DATE PERMIT/SERVICE REDVEST# INVOICE <br /> a`Io Sj ,C>p H mol OO�S�z �o� <br /> C-57_ WC,J WAIVER_ C-57 Letfer of AuthorilcTion to sign permit!Encroachment clot 1 9/27/00 <br /> I <br />