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WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES U1l�ll l"/ LS© <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) v <br />304 E. Weber, Third Floor, Stockton, CA., 95202 JUN 2 9 2000 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is�t1�'�r1 ��V�ht�`dvilb <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Oivlsion <br />Assessor's <br />WELL Location 1645 Cherokee Lane Cross StreetSanguinetti City Stockton zip95205 Parcel# 119-100-05 <br />PROPERTY Owner CA Traction Company Address 2201 W. Washing toncit,Stockton zip 95203 Phonem209-466-6927 <br />C-57 Contrac:or Spectrum Exp. Address 2365 Wigwam Drive CityStocktonzip95205 Lic#512268PhoneiV-09-465-8712 <br />Consultant/ Sub Contractor Hydro—Env. Tech. Address 2394 Mariner Sq. Cityklt.ameda L; N/A Phone,510-521-2684 <br />D l+lt ' <br />GIS Coordinates: X 4204400 mN Y 652400 mE Township- 2N Range 6E <br />WORK TO BE PERFORMED <br />[KNEW WELL I BORING ( CPT, GECPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />14 WELL # 1 to 3 <br />"Other: <br />CGMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />(KN10NITORiNG <br />WOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMEPJDRIVEN <br />0 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 <br />OTHER <br />COMMENT <br />Section 43 <br />0 DESTRUCTION (choose type befo.u) <br />Q OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8.0" MULTIPLE CASINGS? 0 YES ff NO WELL CASING DIA 2. 0" <br />CASING THICKNESS SCh 40 TYPE OF CASING: 0 STEEL R PVC 0 OTHER:_ <br />DEPTH OF GROUT SEAL 10 ft TREMIE TYPE TO BE USED: 0 AUGERS )j..OSE <br />GROUT SEAL PUMPED: )0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 50 ft t BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? No (if YES, list specifications here) <br />ivOTIE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PEKMI I b <br />I hereby certify that I have prepared t` a �r;r!Ication and that the work will be done in accordance wftri ban Joaquin <br />County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />CALL) THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />C t.LtyFi✓�a �ir � T� i:;.e <br />Signed x (i !•� Cr"^ /t,��...Title/Company <br />Print Name <br />(,,J; r(«va„ c��� Date <br />SEE SITE MAP I UNIT IV FILE WORK PLAN DATED <br />Application Accepted By ! w r'c Date Issued L I tC14t'E,-4N GG <br />Grout Inspecticn By Date al Inspection By Z � — <br />Destruction Inspection By Date <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMrrTED I CHECK # <br />e` 11-11^1 <br />RECD BY I DATE <br />n-2-32 ci <br /># I INVOICE <br />