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WELL PERMIT APPLICATION FORM 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 otrzo <br />(209) 468-3449 JUL 2 6 2001 <br />NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County foraermit to construct and/or install the work described. This ap 1 C�tttl� t,l� rrrp!iance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health S4R -8s rvl-slalth Oivis on <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 PhoneT209-466-6927 <br />C-57 Contractor Spectrum Exp. Address 2365 Wigwam Drive cityStocktonz;p95205 Licz512268Phone09-465-8712 <br />Consultant/ Sub Contractor Hydro -Env. Tech. Address 2394 Mariner Sq. Cityk ameda Li, -,N/A Phone„510-521-2684 <br />Suite 2 <br />GIS Coordinates: X 4204400 mN Y 652400 mE Township 2N Range 6E Section 43 <br />WORK TO BE PERFORMED <br />(KNEW WELL! BORING ( CPT, PBORING #OROPUNCH, HAND -AUGER, OTHER') <br />SOI <br />ja WELL # MW <br />'Other: <br />MMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />jMONITORING <br />{HOLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/ORIVEN <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: <br />O OTHER <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8.0" MULTIPLE CASINGS? 0 YES [f 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 1O f t TREMIE TYPE TO BE USED: 0 AUGERS :{!HOSE <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 />COMMENTS* <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />ed this application and that the work will be done in accordance <br />i hereby certify that l have preparwill; San Joaquin <br />County Ordinances, State Latins, and R'UIes and Regulations of the San .loaquin County. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />/Gd�/ Title/Company <br />Signed x �J�Lc{ r iCrr F1.,t �✓� /j6✓D 'rrnu.r'J:�✓ne�.s k %c:_'�. <br />�t 1. rr,�::.. i �,! r, z .✓ Date <br />Print Name <br />SEE SITE MAF' I UNIT IV FILE WORK PLAN DATED <br />oPPAPTMFNT USE ONLY <br />Application Accepted By <br />Grout Inspectlort By_ <br />Destruction Inspection By <br />Data <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />Issued �— i 11G <br />Inspection By f <br />PE CODES I FEE INFO I AMOUNT REMrTTED I CHECK # I RECD BY I DATE �`-I P <br />oc,?,0 I <br />ST # I INVOICE <br />