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11/15/2001 14:02 2094GB3433 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM <br />nPIGIN-Al <br />WIN %.f <br />SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <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 />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 Develupment Title, Chapter 9-11 15.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Divislon. <br />1 �' I I Assessor's <br />WELL Location 2103 LOInnT%N l�lw6 -e>W • Cross Street F,, City A ZIP—Parcell, 111080- 2,9 <br />PROPERTYOwnnler(II` 1111 \��,(�,� X ), Address?-(), ��it 50\04- City Zip 4S8 P1one:�CZi g42 ��OqS <br />-57 Contractoflt/�yt filet J�✓j11, Address 311r, y fzc�Q/�Id� � City /e.��_Zip LIC#�jPhone# IIID' G35• 7?7 iy <br />Gori• } <br />Consultant / Sub Contractor 47 r k VA,_ /s/_Address /. City G�n�nY�LictF� Phone#'ZS• 3L 732, Z— <br />u � <br />GIS Coordinates: X Y Township Range _ Section <br />WORK TO BE PERFORMED <br />0 NEW WELL! BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />WELL if�P•i �SP'B St7- 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />Q MONITORING <br />r HOLLOW STEM <br />0 EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />Q VAPOR <br />0 MUD ROTARY <br />yAIR SPARGE <br />Q PUSH POINT <br />Q SOIL BORING <br />D HAND AUGER <br />0 OTHER: <br />[] OTHER <br />'COM <br />CONSTRUCTION SPECIFICATIONS <br />r <br />DIA. OF BOREHOLE MULTIPLE CASINGS? [j YES #NO WELL CASING DIA: 2- <br />CASING THICKNES O TYPE OF CASING: 0 STEEL`4PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />GROUT SEAL PUMPED; 40Ye5 L0 No (NONCE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: IJPa"l L2w.e.�n/V <br />APPROX BORING DEPTH :*,P I <55 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTdR CASING PROPOSED? P)u (if YES, list speciFlcatinns 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 Ordinan es%,�ulleess%and ons, and all applicable California State Laws. <br />Signed x v ' l� .—Title/Company /�-�/�~�� r''t'.0tAft /wesr���`r <br />Print Namel lam- t cd*hr d �f ' 'x -CMF' Date a • -0 5r -o L <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: C;;'L�/ <br />WORK PLAN DATED: �-` f� ' �' D� <br />Application Accepted By Date Issued <br />Grout Inspection By Date Final Inspection By Date - 'U 2— <br />Destruction Inspection By <br />COMMENTS /CONDITIONS: <br />ACCOUNTING ONLY_ AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMfTTED <br />CH,ECK # <br />R C'D BY <br />DATE PE T <br />INtE <br />3 <br />wd <br />(/SJ dtl <br />tY -onm D O / " <br />) <br />C -57 9/Z7/00 <br />� WC -WAIVER_ C-57 Letter of Authorization to sign perml�-- Encroachment doc <br />