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04/25/2002 08:20 GEOLOOP DPTLLING 4 191G5G5435G <br />- ..- .._.,., <br />r40.079 007 <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PSIS-EHD) UNIT IV <br />mA E Weber Third Floor Stockton CA. 95202 <br />(209) 468-3449 ORIGI <br />NQN-EjEENNQAF3LF. PERMrr EXPIRES 1 YEAR PROM DATE ISSUED NAL <br />%oplication ie hereby made to San Joaquin County for a pormll to construct and/or inwall the work desoribed, This application is made in compliance with San <br />kiaguin County Dov jppmop Titie. C apter 9-4. <br />- i tS.3 and Ute Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />rrt �,,�/ � t.tL (ter ri C) t" _ r Assessor's <br />NELL Locallon �.i� Amma;e. Cress S oe -L Clly ry ip }6 ZZ ! Parcel# <br />'ROPE TY Owner IdreesCiYy`3((,�C Y �'� hi_Zo_�� 7- ci <br />:•57Con1r®clot X�j1rP(}p (.��+ +.►� laresslZ®4 �„ ,�ntc►c�I.f�City � P�Lic 5321vP ane �llk-CN' 5f <br />_.. ,9No <br />-orsultant / Sub Coni ractor�-- -Phon®MVMpp� <br />3)S Coordinates- X_�_ Y Township RBngo _. __ Section <br />NORK TO BE PERFORMED: <br />New yd LL / 90RiN0_[CP7�DEOPROBE, HYDfaOPUNCI-I, HAND -AUGER, OTh1ER-) _0 DESTAUGTION (Choose type below) <br />SOIL BORING ti 11 OVERBORE <br />WELL # ,,1- YIUJ­:1 Q PRESSURE GROUT <br />'Other: Grout Specifications' <br />.:OMMENTS; �t� �v ��c� �c� Yl�l ZZ- z3 Z_oOZ <br />rYPE OF WELL <br />INSTALLATION TYPE= <br />.?KMONITORING <br />'`9 -HOLLOW STEM <br />j EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />7 VAPOR <br />[l MUD ROTARY <br />_j AIF/ SPARGE <br />[)PUSH POINT <br />] SOIL BORING <br />[] HAND AUGER <br />] OTHER: <br />n OTHER <br />'COMMENTS <br />CONSTRUOTlQN SPECIFICATIONS 11 <br />DIA_ OF BOREHOLE_ MULTIPLE CASINGS? U YES CIO WELL CASING DIA: Z <br />CASING THICKNESS SCt>r iiD AT -TYPE OF CASING: [] STEEL 70VC U OTHER: <br />DEPTH OF GROUT SEAL_ _, TREMIE TYPE TO BE USED: [l AUGERS KHOSE <br />GROUT SEAL PUMPED: ❑ Yes Po (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GF OUT SPECIFICATIONS: <br />APPROX. BORING DEPTH � �� � VBOLTED TRAFFIC BOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO (Y YES, Ilst specifications here):-.---_-.... <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 />hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin <br />aunty Orciln ccs, Mules ar14 Regulati ns, and all applicable California State Laws. <br />:iignad x ','"''�'�''.`.�'`",if �/.......D ._ /�� p TillolCompany_JI> > ����L—T�✓��€.i- ���}�' �ic�-�.-. <br />,tl11 Name r'�. V'1 Ci� tx� �l_� .__. __._....... <br />DEPARTMENT USE ONLY <br />3iTE MAP IN UNIT IV FILE, ADDRESS: <br />AIORK PLAN DATED; 12- <br />:-,pplicabon Accepted By—� � —Date Issued v <br />=rout inspection By _ Dasa FInal Inepeclion <br />,asvuciion Inspection By Date <br />"OMMENTS / CONDITIONS <br />4CCOUNTING ONLY;I AIDii I cnrr.a <br />?E CODES <br />FEE INFO AMOUNT REMITTED <br />Gh1EGK # <br />AEC'D BY <br />DATE PERMIT ST U <br />INVOICE <br />RRit <br />-57 <br />WC____. -WAIVER_ <br />C-57 Letter of Authorization to sign permit ✓ncraachment doc 9/27/00 <br />