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12/21/2001 15:51 209-57Q-2225 MODESTO ATC PAGE 04 <br />WELL PERMIT APPLICATION FORM <br />SAN 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 />7- <br />NON-REFUNDABLE PERMIT PIRES 1 YEAR FROM DATE ISSUED <br />Applicadon 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, Chapte 9-1115.3 and the Standardsgf, Sa+j_Joaquin County Public Health Services. Environmental Health Division. <br />^ _ Y,��^ Assessors <br />WELL Location_ pi"` t �� � /� r _cross, Street city City $�G � ^ Zip Parcel# <br />PROPERTY Owner <br />fkAI "'r'"" C ©� Adores, W"L� �` �,p� Crlty -- Zip �t-Phoneii � r� <br />C-51 Contractor lNo�va, ytAj Address 33t- Cit,4N)0gUl- Zip4 Phon,04-07-3,+4'43,46 <br />Consultant/Sub Contractor Ar-rc, FiCS Address 'lt (�►-F7q�w. 5 CityArewa Uc# PhonettS `Z-ZZI <br />GIS Coordinates' X Y Township Range <br />WORK TO BE PERFORMED: <br />EW WELL I BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') <br />0 SOIL BORING # <br />3XWELL # <br />'Other: Grout Speecadons <br />COMMENTS: <br />TYPE OF }HELL <br />INSTALLATION TYPE <br />a MONITORING <br />jIOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />VAPOR <br />0 MUD ROTARY <br />PAIR SPARGE <br />tj PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />Section <br />ty <br />p DESTRUCTION (choose type beloy) <br />0 OVERBORE <br />[I PRESSURE GROUT Q <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE t,. MULTIPLE CASINGS? 0 YES .140 WELL CASING DIA' Z <br />CASING THICKNESS TYPE OF CASING: 0 STEEL ArPVC 0 OTHER: <br />DEPTH OF GROUT SEAL l�-�, TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br />GROUT SEAL PUMPED: p Yes WNo (NOTE:`,MAXIMUM FREE -FALL DEPTH IS 30') <br />^ <br />GROUT SPEC IF [CATIONS; ck '0'� 6A,,.wA%k <br />[I OTHER:_U OTHER APPROX. BORING <br />CONDUCTOR CASING PROPOSED? W <br />*COMMENTS: <br />)!�60LTEO TRAFFIC BOX or 0 STOVE PIPE <br />( if YES, list 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 />} <br />I hereby cartity that I have prepared this application and that the work will be done in accordance with San .Joaquin 1 <br />County Ordinances, Rru�s and=�gylafions, and all applicable California State <br />Laws. ' �r <br />Signed x " �� Title/Company 4:-r c ASS `on_� <br />if <br />Print Name c t� ati X "-` Date I I <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Appilcadan Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS I CONDI'T] <br />ACCOUNTING ONLY; I A] D# <br />` � U Cr1 Date Issued /� 0 <br />Date Z ` knal Inspection By Date <br />Date <br />PE CODES FEE INFO AMOUNT REMITTED I CHECK 9 1 RECP BY I DATE PE <br />C-57— WC -WAIVER— C-57 Letter of Autho tz o sign permit n <br />INVOICE <br />9/27/00 <br />