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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 � �AIooHDIVISION , <br />Stockton, CA. 95202 <br />304 E. Weber, Third 468-3449 <br />NON-REFUNDABLE PE MIT EXPIRES 1 YEAR FROM DATE ISSUED licallon is made In compliance Y'^th San <br />>pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described This app � Assessors _ 2Z1 „( jQ <br />Joaquin County Development Title. Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services�ESZo�m} Pa Assessor <br />Di Ea <br />(y 115 �yu•+ Cl ,, b Cross Street <br />city v__._ --r•- t0 b � � 5 <br />,HELL Location ,� ZiP�rhone# <br />,('D E • ci�� o <br />el -C. 0OtJ Address �� _ 3}y- �� <br />PROPERTY Owner, r '� 945'71 Lim Phone# o <br />r u:r Rri —City .o Vr zip v <br />C-57 Contractor ► �� Address_ f_ O R i f� s I' ar i- 7 4 4 <br />F� r cid } l ,n Litt? __ Phone#•,0-4,5).575 r _ <br />,,II �1(. Addresses t(�a C�_City <br />Consultant I Sub Contractor cTt Range Section <br />Y Township <br />GIS Coordinates: X '— <br />WOKE PERFORM O: DESTRUCTION (choose type below) <br />OVER-80RE <br />PEW WELL I BORING (CPTQ SOIPROR NG apROPUNCH, HAND -AUGER, OTHER') I7 PRESSURE GROUT <br />'WELL F Mw Grout Specifications: <br />'Other: <br />COMMENTS: I I <br />TYPE OF WEL1 INSTALLATION TYPE CONSTRUCTION SPE I IC_L CANS <br />' MULTIPLE CASINGS? Q YES NO WELL CASING DIA: <br />MONITORING HOLLOW STEM DIPS OF BOREHOLE <br />OTl-tER:�� <br />TYPE OF CASING: STE L C Q 'IOSE n <br />0 EXTRACTION IR HAMMERIDRIVEN CASING THICKNESS AL O . TREMIE TYPE TO BE USED: AUGERS <br />0 VAPOR o MUD ROTARY DEPTH OF GROUT SEAL r1 `�� <br />❑ PUSH POINT GROUT SEAL PUMPED: Yes p NLo (NOT : MGA FTE -FALL DEPTH IS 30') <br />0 AIR SPARGE GROUT SPECIFICATIONS: 11 av t ICU. <br />T <br />0 SOIL BORING � HAND AUGER I �OLTED TRAFFIC BOX or � STOVE PIPE <br />0 OTHER:�rB OTHERI APPROX. BORING DEPTH(if ES, list specifications here): <br />CONDUCTOR CASING PROPOSED? _ <br />"COMMENTS: <br />r:retTr anRINGS REQUIRE ACCESS OR ENCROACHME DF PI{EiRPEC ONS. <br />PAGE 02 <br />SAL <br />SITE <br />MITIGATION <br />UNIT IV <br />INV11--.. v.I--.--•--- <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVA <br />if that I have prepared this application and that the work will be done in accordance with San Joaquin <br />I hereby certify California State Laws. �� r � <br />County Ordinan les an gu tions, and all applicable GU� r 1 �_ <br />TIUelCompany �t <br />Signed x pate / o o / <br />PAGE <br />Print Name <br />DEPAK I Mt:N I uv" "'-'- - <br />ul <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />O <br />/ <br />��(� . v <br />Date Issued <br />Application Accepted BY <br />Date Final Inspection By <br />Grout Inspection By <br />Date <br />.. <br />Destruction Inspection By <br />A <br />COMMENTS ICON DTTI11ll11N 11:11i <br />ACCOUNTING ONLY: AIDA <br />P I SERVICE RE <br />PE CODES FEE INFO AMOUNT REMITTED <br />CH�E-CK to RECD BY DATE <br />C-57 Letter of Au�orization to sign permit— <br />�1 <br />C-57_ WCC WAIVER <br />M <br />9/27/00 <br />FEB 23 '01 10:00 2094683433 PAGE.002 <br />