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02/13/2001 08:36 <br />m n �\ - <br />o Err"r,-- <br />":_5 _�EPD <br />OCT 2 4 2001 <br />2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />U K I b+NAL <br />SITE <br />MITIGATION <br />UNIT IV <br />r%IV1Fk0 ,1-',\AENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 96202 /����j <br />-)PR,nAiTigFRVICES (209) 468-3449 �r�- 1 `�J� l <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE LSSUED � <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 com Once with San <br />Joaquin County DlIevelopment Title, Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division_ <br />WELL Location � Of6 tH cz-i} Cross Street Si:x� � Assessor's <br />City 21p Parcel# <br />PROPERTY Owner ( Address City Zip. Phone# <br />C-S7Contractor_�ck'�-^ n`�� "^ AddressCity.S Zip Lic#51226 y Phone# <br />Consultant/ Sub Contractor �-� Ztti1 14 LL- Address 1'6S 6r­� Ave. Clty �-�'04 Uc# Phone# CS+a� - ZS I -LbFb' <br />GI$ Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />1Lr NEW WELL J BORING ( CPT, GEOPR08E, HYDROPUNCH, HAND -AUGER OTHER") 0 DESTRUCTION (choose type below) <br />� 0 SOIL BORING F Q OVER -BORE <br />[] PRESSURE GROUT <br />■Other out Speaflcations: 4ccw�4 <br />COMMENTS: • W*' 1'6's 11", 4, <br />TYPE OF WELL <br />INSTALLATION TYPE <br />,dMONfTORING <br />AHOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMERIDRIVEN <br />Q VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />0 SOIL BORING <br />0 HAND AUGER <br />0 OTHER: 0 OTHER <br />*COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE "i MULTIPLE CASINGS? 0 YES If NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: q STEEL NdPVC 0 OTHER <br />DEPTH OF GROUT SEAL _( O ' TREMIE TYPE TO BE USED: 0 AUGERS 'HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No (NOTE; MAXIMUM FREE -FALL DEPTH IS 301) <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTHAP69O • bOLTEa TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? to (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 />1 hereby CBrtify t t I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordina es, R le an,d Re6gulations, and all applicable California State Laws. <br />1 <br />Signed x r TitlelCompany <br />Print Name �_Qc-+U%—kx / !ter Date 1OIa3 <br />SITE MAP IN UNIT IV FILE. ADDRESS: /(0 — e e) <br />WORK PLAN DATED: O / (D () <br />Application Accepted By. Date Issued /V v O/ Area <br />Grout Inspection By Date Final Inspection By Date %• Z�o"O Z <br />Destruction Inspection By Date <br />COMMENTS / CONDrrIONS: <br />ACCOUNTING ONLY. <br />fl�rffl <br />M', <br />1, AMOUNT REMITTED <br />" �ti <br />•-- ` /-� <br />� Imo._^w�� <br />r 1��,���j1•�� <br />C-57 WC _ -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc ) 9/27/00 <br />s <br />