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RD) E r-9 FE � \\S E 0 <br />WELL PERMIT APPLICATION FORM SITE <br />FEB 13 2001 MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />05 , 2jo (209) 468-3449 <br />s�tf� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application i reby 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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />/� n Assessor's , <br />WELL Location �t ih 4 tm � tR,` Cross Street City i1 j( r 0A Zip 3(I(0 Parcel#Lit 4,11 <br />PROPERTY Owner 0,l rctL (L( pot, _Address__S�_� a Cry oz- Zip�S�Phone# Z d $-j <br />C-57 Contractor (fiJlYMC1 AS50Gkr4l4ddress 2h2 NA&r'k�- City if, Zip 91/001 Lic# 3 4 Phone# 5311t'Iri-9}03 <br />Consultant / Sub Contractor Address__ City Uc# Phone# <br />GIS Coordinates: X__ Y Township I s Range (Zg Section ZQ <br />WORK TO BE PERFORMED <br />j]'NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />[] SOIL BORING # I] OVER -BORE <br />R WELL # �t3 - Zl� %1 2-1,09 (I PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />.MONITORING <br />W HOLLOW STEM <br />[] EXTRACTION <br />n AIR HAMMER/DRIVEN <br />n VAPOR <br />n MUD ROTARY <br />[] AIR SPARGE <br />[I PUSH POINT <br />[I SOIL BORING <br />0 HAND AUGER <br />(I OTHER: [] OTHER <br />`COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE— /9 MULTIPLE CASINGS? n YES )(NO WELL CASING DIA: Z_;nCJA <br />CASING THICKNESS Sch4.Akle y0 TYPE OF CASING: n STEEL 'PVC D OTHER: --- <br />DEPTH OF GROUT SEAL N ?D �t - TREMIE TYPE TO BE USED: D AUGERS n HOSE <br />GROUT SEAL PUMPED: [] Yes jjNocy- <br />: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: U-4#4 <br />APPROX. BORING DEPTH "-S-0 �4 • 'BOLTED TRAFFIC BOX or [I STOVE PIPE <br />CONDUCTOR CASING PROPOSED?— K�p_ (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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordi ance� Rules an Regulations, and all applicable Califomia State Law/s. <br />Signed x (_^ TitletCompanyR� P / / llrn/(PnGe cf�Gcl <br />Print Name l�(/! 't Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNITGl-FILE, ADDRESS; `1 a( S-i-aylcJ3=,=. 4a4 " <br />WORK PLAN DATED: <br />Application Accepted By Lt4 ,6An�.,n-a1. Date Issued s © Area <br />Grout Inspection By W�. AA jx2b� Date 1 IfO Final Inspection By Date_j2 b <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT/ SERVICE REQUEST # <br />INVOICE <br />a d, <br />oG <br />T007. /10 /Z0 <br />SofI SR QQd,5-2- S <br />C-57_ WC --WAIVER— <br />C-57 Letter of Authorization to sign permit_ <br />Encroachment doc_ <br />9/27/00 <br />PA -.3c',y" <br />?-I-1-17-1 HI -IT-4 <br />FPb>^RybF07. 9fi :0T <br />T007. /10 /Z0 <br />V <br />