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02/23/2001 10:05 2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL d Fo <br />AjoHStockton, CA., 5202 <br />TH DIVISION <br />(209, <br />) <br />304 E. Weber, Th 468-3449 <br />SINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PE MIT EXPIRES 1 YEAR FROM DATE ISSU D application is made In compliance with San <br />>pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app Assessors 12-B - 2.31 <br />Joaquin County Development Title, Chapter 9-1115.3 and the <br />Standards of San Joaquin County Public Health Services,�Es2a y Pa ce �alU' Division.�� <br />• zi'�� <br />HELL Location_ 14� I E 1 AM Cross Street r_nt qty j J phone# �D� • �� S <br />I D a city JP <br />j!ipPROPERTY Owned' 1 Address �A �- Z _ 3 E Y3�o <br />�\ \ '145'1 Li�2J� Phone# ° <br />SSO [ .0 _City ,d r 1 Zip <br />C-57ContractorL/,.�.,�,,rl �r�����C Address / J S. I�')n Lia4kp- <br />IIII Tin Address _?g2.5irir �S 'j <br />Consultant / Sub Contractor �P1T r- V -"� r— Range Section <br />GIS Coordinates: X <br />Y ,Township <br />W K TO BE PERFORMED: 0 DESTRUCTION (choose type below) <br />OVER -BORE <br />NEW WELL 1 BORING ( CPT, GEOPR08E. HYDROPUNCH, HAND -AUGER, OTHER) 0 PRESSURE GROUT <br />0 SOIL BORING # <br />'WELL # Grout Specifications: <br />'Other: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />Q AIR SPARGE 0 PUSH POINT <br />0 SOIL BORING 17 HAND AUGER <br />[] OTHER:_`_[] OTHER <br />II <br />CONSTR CTION P IF'CATIONS YESu NO W ELL CASING DIA: <br />DIA OF BOREHOLE --a— MULTIPLE CASINGS. [] ! E OTHER -.r <br />CASING THICKNESS-y—"�TYPE OF CASING: []STEEL PVC Q <br />7REMIE TYPE TO BE USED: 0 AUGERS OSE <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: Yes 0 No (NOTE:�r!MUM FREE <br />DEPTH IS 30') <br />arT v` <br />GROUT SPECIFICATIO : <br />APPROX. BORING DEPTH O OLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_Y_0 (if YES, list specifications here): <br />....r �.�,- r,npIK1r:R REQUIRE ACCESS OR ENCROACHMENT PERM I�TIIONS. <br />ALL - <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br />'f that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />I hereby certify California State Laws- / <br />County Ordina s ul R ulations, and all applicable 1// o <br />TIUerCompan O / <br />Signed x Oate r r <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection <br />Destruction Insp <br />COMMENTS f CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />I V0 <br />-U� <br />Date <br />inal Inspection By <br />RECD BYI DATE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK;•► Z <br />R5 i <br />C-57— WCWAIVERC-57 Letter of Authorization to sign permi <br />= _ <br />401, <br />SERVICE <br />vzT <br />AM N <br />INVOICE <br />S <br />"Z/itc , <br />9/27/00 <br />FEB 23 '01 10:00 2094683433 PAGE.002 <br />