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02/23/2001 10:05 2094683433 <br />FIFTH FLOOR <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 />ORIGIRAL <br />Saw, ----M <br />SITE <br />MITIGATION ON <br />UNIT IV <br />NON-REFUNDABLE PE MIT EXPIRES 1 YEAR FROM DATE ISSU D application is made in compliance with San <br />application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app Assessors <br />Joaquin County Development Title. Chapter 9-1115.3 and the Standards of San IJ`oaquin County Public Health Services, Environmental Health Division. <br />r_.; FTn �Cily '-'2Parcelif <br />Cross street <br />NELL Location 0,Phone# Z <br />6 Address��o C Crty- �satl 11�- <br />PROPERTY Owner, � � U $�zf2Lic& (?5."Phone# <br />�I!✓ 2 AddreS'- <br />?254,�.i P _City��zip <br />C-57 Contractor til h Ue#�Z f`"I •Phonoi- 2� SSI- �`?5 - <br />:, z�c. Address fi S rc C� City <br />/ Sub Contractor Section <br />.Township Range <br />GIS Coordinates: X Y <br />WORK TO SE PERFORMED_DESTRUCTION (choo6e type below) <br />[] OVER -BORE <br />0 NEW WELL I BORING ( U- i. GEOPR00E, HYDROPUNCHi HAND -AUGER, 0 i R�) PRESSURE GROUT <br />SOIL BORING <br />WELLS C��Ln r c <br />0 Grout Specifications:,,, <br />'Other. <br />COMMENTS: <br />TYPE OF WE L INSTALLATION TYPE CONSTR CTION P iwl; ATIU TtPLE CASINGS? 0 YES + NO WELL CASING DIA: <br />HOLLOW STEM DIA. OF BOREHOLE OTHER: <br />p MONITORING 13 TYPE OF CASING: 0 STEEL 0 PVC 0 <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS AUGERS HOSE <br />0 VAPOR MUD ROTARY <br />DEPTH OF! GROUT SEAL 7REMIE TYPE TO BE USED: D <br />AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 1 Yes 0 No (NOTE: MAXIMUM FREE <br />DEPTH IS 30 <br />'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br />OTHER APPROX. BORING DEPTH <br />0 OTHER'- _ �� CONDUCTOR CASING PROP SED? N % (if YES, list specifications here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENTALL 1� INSPECTIONS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br />reb certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />I he y Y <br />County Ordinance , Rul s, r, dRegulations, and all applicable California S Gf aws <br />.�k rs c /tr _ N -��C• <br />Title/Company <br />Signed x <br />Date <br />Pnnt Name h e �' n�vnRTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issued <br />-2W-01 Area - <br />Date Final Inspection By <br />Application Accepted By te_ <br />Grout Inspection By <br />Destruction Inspection BDatey n, <br />COMMENTS t CONDITIONS: <br />ACCOUNTING ONLY: AID# R54liEST g INVOICE <br />PE CODES FEE INFO AMOUNT REMfTTED CHECK 0 RECD BY DATE <br />9/27/00 <br />C -57 <br />C-57 WCC WAIVER_ C-57 Letter of Authorization to sign permit �Enc�oachment doc_,,r <br />FEB 23 '01 10:00 2094GG3433 PAGE.002 <br />O <br />