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05-18-2001 07:44RM FROM TO 19166358805 P.02 <br />REC )1 WELL PERMIT APPLICATION FORM <br />SAN JO/OUIN COUNTY PUBLIC HEALTRSERVICES MAY 2 5 2001 <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRUNWItill tiLAL1h, 304 E.Meber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SER\RCES (209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRE 5 1 YEAR FROMDATE ISSUED <br />Application is hereby made to San Joaquin CountY,fcir a permit to construct and/or install the work described. .This application is made in compliance with San <br />Joaquin County DeveloMTJA,etha t r 9-111 .3 e Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />PROPERTY Owner Mr. leery 0-r-cii-t 't; Address 1 1.-14:, t\i, iitOtarif city 1,,,J; Zlp S.--2 Phone# - <br />_ <br />C-57 Contractor 62Yer 04/4.:7 Address '1.b2) ''')Q catj City ArligeZ, Zip *53:3Lic#66741Z6/644-ione#(Y25) 3/3 — 56ce, <br />Consultant / Sub Contractor 13/24-00 4 (-1,- /e/ i Address Z 761 Pcospeci 1(24.. Of Cityg i 1 4‘40 4vcilacilt Phone tt 6/0 17l`f"/- O i 2 3 \ - <br />V) <br />SITE <br />MITIGATION <br />UNIT IV <br />\ (// 4114.1al.. WELL LocatIonilAWV tW-J f v v. Ter' ". ross'Street City 'Zip • • Parcel# <br />Assessor's <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />KNEW WEL NG)CPT, GEOPROBE, HYOWPUNCH, HAND-AUGER, OTHER') <br />ArSOIL BORING #i ---1 ) P-3 <br />a WELL#' <br />'Other: <br />COMMENTS: .ke.k nil 4,6) <br />TYPE OF WELL INSTALLATION TYPE <br />I] MONITORING a HOLLOW STEM <br />EXTRACTION a AIR HAMMER/DRIVN <br />fl VAPOR UMUD ROTARY <br />AIR SPARGE rl PUSH POINT <br />AIZOIL BORING 0 HAND AUGER <br />0 OTHER: WOTHER <br />p DESTRUCTION (choose type below) <br />DOVER-BORE <br />PRESSURE GROUT <br /> Grout Specifications: 0.2.,•vravAn. <br />(t) i cc <br />CONSTRUCTION VECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS' 13 YES n NO WELL CASING CIA: <br />CASING THICKNESS <br /> TYPE or CASING: fl STEEL a PVC 13 OTHER: <br />DV'TH OF GROUT SEAL TREMIE TYPE TO BE USED: fi AUGERS a HOSE <br />GROUT SEAL PUMPED: a Yes g No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />4f,-; PPROX. BORING DEPTH fl BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHNIENTFERMITS. <br />CALL THE UNIT IV INSPECTdR 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 and Regulations, and all applicable California State Laws. A i <br />6ezieLda ric)i ed 111114vIt Signed tt Title/Company <br /> Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRES : r\ ct <br />WORK PLAN DATED: 10 <br />Print Name: 1/14 r--ttA-ctr <br /> Date <br />Date <br />Date Issued 513,14L, <br />Final Inspection By7r1. <br />Area <br />Date <br />Application Accepted By <br />Grout Inspection By —7.rk <br />Destruction Inspection By <br />COMMENTS! CONDITIONS <br />ACCOUNTING ONLY: AID#tv,a FAC# 3Z) <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />D 11 A '2) 3 6-7 b3 sR# a• it:72-39 <br />C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 C-57 WC -WAIVER