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12/07x'2000 X39:52 2094G834:'3 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM <br />b AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON REFUNQABLE PERtY11T EXPIRES 1 YEAR FROM DATE IJED <br />)plication is hereby made to San .loaqum. County for a permit to ccrstruct and/or instati the work described- This application is made in Compliance with San <br />:aquin County Development Title, Chapter 9-1115.3 OrrC the Standards of San Joaquin aunty Public Health Se ices, Environmental Health Division. <br />Assessors _ <br />cLL Location i v,1 x r Gross Street :J City tp Parcel# �2207 T <br />ROPERTY Ovvner �l i I Li J��Address �� wf'~ City c, zip'l <br />-57 Contactor �i <br />ir12 ddrass G ' ��� Zip ytK L�'C Sz�i7u�PNonei�_ y 1.3 3,'��3kjj <br />Gc CS I 'LLC Address � 1 ci[y �'Y; Lic# C� Phone#i6 T Ta tfi 38 LL G,`l, <br />onsuitant I Sub Contractor W <br />,is Coordinates. X--, Y. <br />Township <br />Rsnoe Section <br />lORKTO BE PERFQRMED: DESTRUCTION (ctioase type OW) <br />NEW WELL ! BORING (CPT. GEOPROSE. HYDROPUNCH, HAND -AUGER. 07HER") WOW) <br />OVER-BORE <br />[] <br />SOIL ECRING # PRESSURE GROUT <br />WILL# i_,:n,Or Lh:a I►1C�t r ✓� `7 0 <br />t they: 17- Grout Sj;6cifcations: <br />,OMMENTS: <br />YPE OF WELL <br />INSTALLAXION TYPE <br />rUONITORING <br />HOLLOW STEM <br />I EXTRACTION <br />[I AIR HAMMER,10R!VEN <br />I VAPOR <br />[I MUD ROTARY <br />] AIR SPARGE 0 PUSH PAINT <br />j SOIL BORING Q HAND AUGER <br />OTHER;_[) OTHER <br />COMMENTS; <br />CONSTRUCTION SPECiFIC�ATIONS I 1 <br />D1A. OF BOREHOLE �r_" V mULTIPIE CASINGS? DYES Q NO WELL CASING DIA, <br />CASING THICKNESS �Z TYPE OF CASING: [) STEEL �C [] OTHER: <br />DEPTH OF GROUT SEAL QO _ TREMIE TYPE TO BE USED: AUGERS U HOSE <br />GROU? SEAL PUMPED: res 0 No (N TE: MAXIMUM FREE -PALL DEPTH IS 30}) <br />GROUT SPECIFICATIONS:_ f� �ar� W ( ; .5-7 a, ,4e <br />ApPF�OX_ BORING QEPTH I iBOLTED TRAFFIC SOX or 0 STOVE PIPE <br />CONOU070R CASING PROPOSED? (if YES, list specifleations 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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Ruses and Regulations, and all applicable California State Laws. <br />iTitlalCompany Q <br />S"elvj� f / <br />,.vgned <br />dint Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />0. P GJ <br />Application Accepted By <br />Grout Inspection Fi to—� <br />Destruction Inspection By <br />Date <br />COMMENTS/ CONDITIONS: <br />ACCOUNTING ONLY: I A] D# <br />PE CODES FEE INFO AMOUNT REN1rr FD CHECK # <br />3 5 01 �f-8 <br />C-57,_,_ We -WAIVER_ C-57 Letter of Auth <br />I <br />e Issued G / <br />at Inspection t?y <br />< 0 YJ l� ► < < �r�` <br />REC'D BY I DATE <br />permit <br />INVOICE <br />9/27/00 <br />