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11!30/2000 15:21 <br />VED <br />2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SITE <br />APR - 2 2001 SAN JOAQUI'N COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIE OMVIENI HEALih ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />PERNIMSERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 / <br />(209) 468-3449 ��� oiq <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application 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 <br />-9--/1115,..3,,,and <br />, the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />aka S Na b Lf fa fS 2 1 �4 T / p Assessor's <br />WELL Location � Cross Street � ,, City Zip ParcEl# <br />PROPERTY Owneri � "( Sk:.s inn Address4,12SA/. 61 Z104do .5 City (1 ZipgS�7_Phone# <br />2�/ 1_ 7a'l <br />C-57 ContractorUt/ N{��1b Address esc. o city 1 ► LZip�Lic#],I�2SPhone# vW 43m <br />Consultant / Sub Contractor—air _ Address 22&s:P0rL,11p &.Ci;;f!.gQ5kAd&ie# 4O Phoned# 4eO2- 4t7I D <br />GIS Coinates; X Y Township Range Section <br />A' (�n ( i r& ' r PVr &hr, -7- O 13-1, 1405 S. 4 �r do Sf'. S o <br />woRK To PE Fo E <br />U NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) J[ .DESTRUCTION (choose type below) <br />0 SOIL BORING # J1,0VER-BORE <br />Cl WELL # 0 PRESSURE GROUT <br />*Other: Gr ut Sp Ifl tions: <br />COMMENTS: 1►Ine L n e I ti r>7 �nrlt �-!lila /Y D�-FYiAr. rrv►n r� c M �.Te c <br />TYPE QF WELL <br />INSTALLATION TYPE <br />' { MOWTORING <br />I] HOLLOW STEM <br />[I EXTRACTION <br />a AIR HAMMERJDRIVEN <br />0 VAPOR <br />a MUD ROTARY <br />i1 AIR SPARGE <br />0 PUSH POINT <br />CONSTRUCTION SPECIFICATIONS <br />DIA_ OF BOREHOLE MULTIPLE CASINGS? []YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: U STEEL H PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO eE USED; a AUGERS 0 HOSE <br />GROUT SEAL PUMPED; 0 Yes d No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:_ <br />a OTHER: a OTHERAPPROX. BORING DEPTH I7 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />-COMME <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications he <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, Rules -and Regulations, and all applicable California State Laws. <br />Signed x �2AV �G �r Title/Company <br />Print Namel I oh"Iei <br />DEPAI <br />SITE MAP IN UNIT IV FILE, ADDRESS: 166)s <br />WORK PLAN DATED.' 3 -2-0o 0 <br />Appliration Accepted By. <br />Grout Inspection By <br />Destruction Inspection B <br />COMMENTS I CONDITIONS: <br />MENT USE ONLY <br />Date Issued_- <br />Final Inspection Ey <br />e /0 <br />.• <br />ACCOUNTING ONLY- <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMRTED <br />CHECK # REC'b BY DATE PE UEST 7t <br />INVOICE <br />3562- <br />wb <br />C-57 WC-WALVER C-57 Letter of Authorization to sign permit Encr en oc 9/27/00 <br />