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10-24-2000 03:40PM FROM TO Y t 15306766005 P.02 <br /> H[N-W WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> 1. OS SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 02 OCT 25 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> F 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> App cation 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 Services,Environmental Health Division. <br /> ''11__ r.' I 1 Asseswes <br /> WELL Location! 5c")u�l b r k�G'� Wcwl Cross Street City � Lk r Zip r, Parcel# <br /> PROPERTY Owners Ar w �,__ AddresS 4 p�ov1 D/, City.L4. ('ai'» , Zip l z3 Phone; p <br /> C-57Contractor G'�7 �Y1-5i�_.-- Address t� Wt lift, City �! Zip ±5J. ^Lim N Phone#7,25-313-5 & <br /> Consultant Sub Contractor !J'! _L <br /> Consultant GitM$N.P-t ID,� City Pc Uc*_. Phone#5✓d�76 <br /> 55D s��u Goo g <br /> GIS Coordinates'X Y Township _Range $eGtion <br /> i <br /> MRK O gurwogmgC� <br /> NEW WELL 1 BORING(CPT.(; OPROBE.HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION(goose type below) <br /> 50IL BORING# CPT=I Q OVER-BORE <br /> 6 WELL# p PRESSURE GROUT <br /> "Oth4r•, Grout Specifications!" <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING p HOLLOW!STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES p NO WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING; U STEEL Q PVC U OTHER: .. <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TRE MIE TYPE 70 BE USED: o AUGERS 0 HOSE <br /> 17 AIR SPARGE `�USH POINT GROUT SEAL PUMPED: ©Yes []No .(NOTE: MAXIMUM FREE-FALL DEPTH 1S.30') <br /> VOIL BORING ©HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: OTHER APPROX-BORING DSpTHJ ZD _ p got-TEE)TRAFFIC BOX or a STOVE PIPE <br /> C 14DUCTOR CASING PROPOSED? (if YES,list specificatiCns here): <br /> 'COMMENTS•C ! bol-i-'Z] (M A/0 411 _. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V 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 Sart Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Tine/Company ----- <br /> Print Name 5coj: Date 1L?j5`DZ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES : i 3o- 5° W41 5CWORK PLAN PLAN DATED: c63 4,/f fi Z <br /> Application Accepted By Date issued f-��/f'(/rs*11L� �t Ates <br /> Grout Inspection By Data Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS I CONDMONS: <br /> ACCOUNTING ONLY: AID- <br /> Pts CODES FtE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST S INVOICE <br /> 35oi 0 $9 1 .?9 -'019 DO 3188 <br /> C-57,_,_,„ WC -WA1VEi2_ C-57 Letter of Authorization to sign pertmit Encrcachrnent doc_ 9/27/00 <br /> TOTAL P.02 ` <br />