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10-24-2000 03:40PM FROM TO <br />WELL PERMIT APPLICATION FORM <br />Al ; Y 6 2005 <br />E/VVJR0ft'1 <br />l <br />PC-RP✓;IT1 R�ESTt, <br />15306766 RI G I N A L <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 />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Applioation 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 a-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division, <br />�o� // 1 jj-- -- (� Assessor's <br />WELL Lvoation i_G� 1tilfLl 00) Q)ud, S�Gj �( )m Cross Street 4 —S City k rym zip -IS -/L' `! Parcel# <br />�1T <br />PROPERTY Ownerl LII15� j �A Wc* Address_II 10) I / t LG"'�t IJ�J��nq City I Zip ) ZF Phonex '�6-5 � a) `1- `' <br />C57 Contractor 01eq-, 10% S; h/ Address,) sU Hol? 1�, Citvl/IAS ��n✓� 7in�ySti ; l tom_ �n ; 4�: �Phnnoe �0�5- �1 � �i9D� <br />Consultant/ Sub ContractorJfa l�' Fr1�'.t�ttwhV� Address? _6mgwi, <br />GIS Coordinates: X Y To ns�ip 55� <br />WORK TO BE ERFORM <br />'R111 EW WELL / BORING CPT,'GEOPROBE, HYDRO UNGH, HAND -AUGER, OTHER") 0 DESTRUCTION (choose type below) <br />SOIL BORING # Q. I_ I uj -,z t D OVERBORE <br />0 WELL # C;� j - C!" (,� G� _� PRESSURE GROUT <br />"Other: Grout Specifications: <br />COMMENTS: <br />City ► U''1ldt��Phone# 5 X76 �y�Z <br />Range <br />Section <br />TYPE OF WELL <br />INSTALLATION TYPE <br />0 MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />p MUD ROTARY <br />0 AIR SPARGE <br />VUSH POINT <br />SOIL BORING <br />0 HAND AUGER <br />Q OTHER <br />OTHER <br />`COMMEN <br />lY <br />Q <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE::�Jj!_l_ MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL (] PVC n OTHER: <br />DEPTH OF GROUT SEALT� TREMIE TYPE TO BE USED: (j AUGERS BIOSE iF1y k' -- <br />GROUT SEAL PUMPED: tYes 0__No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30')' <br />GROUT SPECIFICATIONS: (j 2 2c, 'j f <br />APPROX. BORING DEPTH i 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? 000 (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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances ul and Rqptitoions, and all applicable California State Laws. <br />Signed x Title/Company Z5 <br />G <br />Print Name (�J/r, l f'l� �u�%V Date �S ��/�( <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: Gil <br />Application Accepted I <br />Grout Inspection By <br />Destruction Inspection <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />Date <br />al Inspection By <br />W Z- "I' <br />fo <br />ACCOUNTING ONLY: <br />AIDP <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />�REC'7DRTYDATE <br />PER OEREQUSST # <br />INVOICE <br />Sib lot <br />C-57_ WC_ -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />TOTAL P.02 <br />