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10-24-2000 03:40PM FR€JNS t TO 15306766005 P.02 <br /> rr. ` ,� <br /> WELL PERMIT APPLICATION FORM SITE \ <br /> "tT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 5 <br /> P l UNIT IV <br /> 2 ENVIRONMENTAL NVi ME <br /> 02 0 RON NTAL HEALTH DIVISION (PHS-EH©) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-3449 <br /> NON-REFUNDA13LE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby tirade 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 /> � r.f [ /�, Assessor's <br /> WELL Lvoation p❑ JDu IN t 156�1{ We Crost`s�FStreet City. � Zlp r,�y Paroet# <br /> PROPERTY Owner r f S—�t+7 Addressq oD', D , City. Zip lUYIZ3Phone;; <br /> ""7Conbmrtor G.'t. C1 1Y1��i 1 Address I� WQ 0 a - h Zip w5} 3l,i r sro PhOrle# �u7`3J'3-5 L} <br /> Consultant!Sub Contractor A)LI Addresa3,33�� G�+�i P t.i�,# City�i cu/ Lick Phone# <br /> - 55i7 <br /> G18Coordinates:X 'y Township Range. Section <br /> -- <br /> WORK TO BE E F N 0- <br /> NEW WELL!BORING(CPT.gEOPROSE,HYDROPUNCH,HAND-AUGER.OTHI=R') p DESTRUCTION(choo§etype'beIcW) <br /> -ffSOIL BORING# CPT--1 1]OVER-BORE <br /> 0 WELL# 1]PRESSURE GROUT <br /> "Other: Grout Spedfications: <br /> COMMENTS: <br /> TYPE OF WEE1 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 17 MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z MULTIPLE CASINGS?[I YES [INC) WELL CASING DIA: <br /> i]EXTRACTION [I AIR HAMMIERA?RiVEN CASING THICKNESS TYPE OF CASING: []STEEL G PVC U OTHER: <br /> a VAPOR o MUD ROTARY DEPTH OF GROUT.SEAL TREMIE TYPE TO SE USED: 0 AUGER$ o HOSE <br /> ]]AIR SPARGE `g6USH POINT GROUT SEAL PUMPED: []Yes []No .(NOTE:MAXIMUM FREE-FALLdEPTI-I !S'30') <br /> VO)L BORING 11 HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH 17y _ p BOLTED TRAFFIC BOX. or a STOVE PIPE <br /> DUCTOR CASING PROPOSED?Kg4 ' (if YES,list specifications herey: <br /> "COMMENTS:C/}i; 's } OYl Ani) 4 rrC Nr, - <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 /> a County Ordinances, Rules and Regulations,and all applicable California rState'Laws. <br /> Signed xTitlefCompany�_ l [ 'S+� ,, ✓a S 1?vt v►4lj?Hzu c/ruj C r <br /> Print Name_ SCG .�7', k E,.1 _Date 10-15-DZ - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 13C S. W t'lkt- <br /> H— <br /> WORKPLANDATED: b3 USF O Z. <br /> Application Accepted Sy — Date.Issued �-��Gy�" s' VZ Area <br /> Grout Inspection 8y Date __ - -Fina!Inspection By ..... . ... Date <br /> r Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# y <br /> a <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMrr 13ERVICE REQUEST#. INVOICE <br /> 3501 039 S9 Ulg' 0031884 <br /> C-57,__ W,-WAIVER, C-57 Latter of Authorization to sign permit . Encroachment doc 9127/00 <br /> ;j <br /> TOTAL P.02 { <br /> i3 , <br />