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08/02/2000 09:42 2094683433 FIFTH FLOOR 0 <br />OTT NAL <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />c) t <br />1pplioation is hereby made to San Joaquin County for a permit to construct andlor 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 />Assessor's <br />HELL Location 0 N • m0.�r S �2e"C Cross Street S}f city A>1Je,cA zio�S 3 3 G Parcel# -1-1 — 0q1-01 <br />c.p w a .-dam ` 1� <br />'ROPERTY Owner De-XQ c- s_ GA o zA_ Address 0 &' Y- PQ '1ZOlty \gri�2 �Zip S 33 Phone# d09 39- 19 <br />1�,o qoy <br />D� <br />Address o29�S ` ISI -57 Contractor <br />'onsultant / Sub Contractor <br />31S Coordinates: X , Y. <br />OVORK TO BE PERFORMED: <br />I NEW WELL l BORING ( CPT, GEOPROBE. HYDROPUN <br />N SOIL BORING # G <br />fl WELL #d <br />'Other: <br />;,OMMENTS: <br />dress City Lio# Phone# <br />Township flange Section <br />HAND-AUGEVOT R-) D DESTRUCTION (choose type below) <br />Ytio C) N a OVER -BORE <br />p PRESSURE GROUT <br />GROUT SPECIFICATION <br />TYPE OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING a HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? DYES 0 NO WELL CASING DIA: <br />[] EXTRACTION fl AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING' 0 STEEL U PVC 0 OTHER. <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS DHOSE <br />a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />SOIL BORING n HAND AUGER GROUT SPECIFICATION <br />[] <br />OTHER:_0 OTHER _ APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County, <br />* CALL -THE UNIT IV IN CTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed x ``� ) Title/Company � <br />Print Name �c`� hOio� Ary�l Date a- <br />SITE MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK 0 <br />350 <br />C-57 <br />I--IS--01 <br />Date Issued 2 <br />Final Inspection By <br />RECD SY I DATE <br />.21.,•aY1-qRlt 0025 <br />WC/WAIVER C-57 Letter of Authorization to sign permit <br />INVOICE <br />7/00 <br />Z <br />