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r R/912,2 347 <br />WELL PERMIT APPLICATION FURM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />SITE <br />MITIGATION <br />UNIT IV <br />Address 9,k i e o -1-0s+e_ P.461. City -Tracy Zip_g_g_kPhone# 009) ce35-- ‘517 <br />PROPERTY Owner 1.6e.. 1691-e. 3'C. <br />C-57 Contractor ii.,,,e5-i-- f1ra2, fv-wa Address 34 q -Fliz <I- e raid -44' City 14".110 Zip q5-670 Lic# $'172? Phone#06 ) 3,V- 7i) 76 <br />t <br />Consultant! Sub Contractor Ataincei 6,(Z-vItA Address 433'7 SL I erw RJ city S-37:-440-Lic# Phone#62G/9 4/6 ? ./aZ <br />GIS Coordinates: X , Y , Township W -L-' - Section <br />ENVIRO <br />*Other: Grout Specifications:NMENT FiEA LT' <br />COMMENTS: <br /> pERAIi.r/ <br />SET? VICES <br />304 E. Weber, Third Floor, Stockton, CA., 952 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU <br />Application 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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />Cross Street( Claioritti City Ca(-1 zip parcel# z.23 g -0 (.)-0411 Assessqr's <br />WELL Location ,-)27,55 I (fife. 94..xto. <br />WORK TO BE PERFORMED: <br />*JEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) FEB 2 ei n.11TrUCTION (choose type below) <br />fl SOIL BORING # I] OVER-BORE <br />p WELL # a PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE <br />VAONITORING ,›KHOLLOW STEM <br />[]EXTRACTION a AIR HAMMER/DRIVEN <br />APOR p MUD ROTARY <br />- SPARGE a PUSH POINT <br />a SOIL BORING fl HAND AUGER <br />a OTHER: [1 OTHER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 3b. " MULTIPLE CASINGS? 0 YES Alq0 WELL CASING DIA: --.... <br />CASING THICKNESS ,i; " TYPE OF CASING: a STEEL p PVC a OTHER: <br />DEPTH OF GROUT SEAL S ' TREMIE TYPE TO BE USED: ,&AUGERS 0 HOSE \i.... <br />GROUT SEAL PUMPED: p Yes 1/No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: q1-1 6 44c1( Vorkkv7et 1-0 6 ,41/0r)>' 1/%44 er <br />APPROX. BORING DEPTH ,9'0% *BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Aie ( 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 />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules a Regulations, and all applicable California State Laws. <br />Signed x Title/Company CA-44 (0)0/ 571 <br />Date <br />Print Name 6c1culi AA illynavN <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: >`->epieA^L)eir a4)00 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />..CCOUNTING ONLY: <br /> AID# <br />Date Issued ) 200 1 Area <br />Final Inspection By Date a <br />Date <br />DaV <br />FAC.# <br />AMOUNT REMITTED CHECK # REC'D , 113 <br />3S-(7 OO clr,110 <br />C-57 WC -WAIVER C-57 Letter of Author atio <br />DATE <br /> PERMIT / SERVICE REQUEST-4 INVOICE <br />370,0 <br />sign permit Encroachment doc 9/27/00 <br />SR# 25 1-1-0.3.- <br />PE CODES FEE INFO