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10-24-2000 03:40PM FROr•" TO 15306700005 P.02 <br />AID; <br />WELL PERMIT APPLICATION FORM SITE <br />PE CODES <br />MITIGATION <br />AMOUNT REMITTED <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />REC'D BY <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br />INVOICE <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />\ <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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />I c r Assessor's <br />WELL Location +� yeGCiJp I,[-OA� �. 11 �� Cross Street City ) I(�I%V1 Zip (-)1- Parcel# stony <br />I I- q t <br />PROPERTY Owner 4 IQtk I�Y� Addresst r h- I City r; 7 Zivy 5k Phonex x�y -r 3 7-`�u» <br />C57 Contractor(,, f'L . i �LL�+ �t h Address�j % IiU�11� City Ew�� n P� 2ip� 5 Lice 1 Phone#x!,25 3i3 5, -Z/ <br />Ztit <br />Consultant/Sub ContractorCllfitlUSrAv�rMm;T� nld r. Addres4J)(i_�176?��11"+�iZ' �.:"h15�Ci ''' '4 !'�1 Lic: Phoned -I30 E 7�" 7 <br />GIS Coordinates: X Y Township Range -Section <br />, <br />WORK TO BE ERFO M -D- <br />EW WELL/ BORING ( CPT, EOPROBE. HYD OPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />OIL BORING # C� 1 -3I ( I - `i Q OVER -BORE <br />WELL# 1YO)i -h, 14yu -jZ PRESSURE GROUT <br />"Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES MO WELL CASING DIA- <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_T TYPE OF CASING: 0 STEEL PVC 11 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I' TREMIE TYPE TO BE USED: D AUGERS o HOSE <br />r� <br />1 ` <br />0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0Cfes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30)SOIL <br />BORING 0 HAND AUG GROUT SPECIFICATIONS: <br />0 OTHER: OTHER APPROX. BORING DEPTH i I� J'BOLTED TRAFFIC BOX or U STOVE PIPE <br />4 �� <br />CONDUCTOR CASING PROPOSED? vk; (if YES, list specifications here): <br />`COMMENTS: `_� `�114.1> � +rk,W{t(Gnrtl liiCllS 1� I',"% •<<: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. �I <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, R lies and Regulations, and all applicable California State Laws. _ <br />L �{ <br />Signed x �la'w /Title/Company <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By_ + Date issued I_Z I �dl' Area <br />Grout Inspection By_�a� MA zlC Date , CI Final Inspection By (A ,vim Date <br />Destruction Inspection By ✓ Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY. <br />AID; <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMFRVICE REQUEST # <br />INVOICE <br />5-0( <br />SR# C20L5 l <br />C-57_ WC_ -WAIVER,, C-57 Letter of Authorization to sign permit^-- i_ncl"oachtnent_dflc-- 9/27/00 <br />TOTAL P.02 <br />