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RECEVED WELL PERMIT APPLICATION FORM <br />APR _ 2 2001 SAN jOAQUiN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 PERMIT/SERVICES (209) 468-3449 <br />NON-REFUNDABLE PERMT1 EXPIRES 1 YEAR FROM DATE ISSUED <br />1pplication is hereby made to San Joaquin County far a permit to construct andIor install the work described. This application Is made in compliance with San <br />loaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />NELL Location Assessor's -46e/2_011 c. S-7- Crass Street/A c /t.S a rs-1 City fici-;-/t-r---J Zip .1"----26-6. Pascellt <br />TIL)PERTY Owne C k , ?'E Str le irx_Address 4,Z:t5j IQ' I{ (.'1(11.(e,, City yr r— :. k zipp,—.2.,,§khone# ci 3. - _ , <br />4 <br />;-57 ContractOlijr/4. T-ci Address0 Goy City RA 0 Vt5/r/ Zip Cff5-7/ Lic411°°71 Phone#e" 34 cf306 ..? 3 3-6 <br />:onsultant l Sub Contractor_l/Ir 4.1 Address City Lie; Phone# <br />SIS Coordinates: X a6 . Y ,Township Range Section <br />NORK TO BE PERFORMED; <br />)6] NEW WELL! BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') g DESTRUCTION (choose type below) lj SOIL BORING # 0 OVER-BORE <br />0 WELL # a PRESSURE GROUT <br />'Other: Grout Specifications: <br />SITE <br />MITIGATION <br />UNIT IV <br />7.:OMMENTS: <br />fYPE OF WELL INSTALLATION TYPE <br /> <br />"Ag MONITORING )1:11OLLOW STEM <br /> <br />EXTRACTION flAIR HAMMER/DRIVEN <br />] VAPOR Li MUD ROTARY <br />] AIR SPARGE 13 PUSH POINT <br />J SOIL GORING El HAND AUGER <br />a OTHER: ri OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE _Z_ MULTIPLE CASINGS'? I] YES...:CNO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: C STEEL 13 PVC 13 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO EIE'USED: (3 AUGERS HOSE <br />GROUT SEAL PUMPED: El Yes No (NOTE: MAXIMUM FREE-FALL DEPTH* 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH / (10 <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />U BOLTED TRAFFIC BOX or U STOVE PIPE <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL PIE UNi I 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 0 , Rules Regulatio , and all applicable California State Laws. <br />Signed x Title/Company C .? /e fiVer- ' <br />Print me \._i <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date '71.,2-,•/a/ <br />Date Issued Lk N-1 <br />Grout Inspection By14.41 _Date I for Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS. <br />Application Accepted By Area <br />Date <br />ACCOUNTING ONLY: <br /> — <br />Al D# FAcp_____ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REG'D BY DATE EQUEST # INVOICE <br />1 C : e 0 2- <br />WC -WAIVER C-57 Letter of Authorization to sigripermit ----eficroechment-ttee---- • 9/27/00 C-57