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. 10-24-2000 03:40FM FROM <br />TO 15306766005 R.02 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 ORI.GNAL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 />WELL Location 47p <br />, Assessor's <br />Cross Street •City S7-;>e-k lo •-•\ Zip /5-2 c"Z-Barcel# <br />PROPERTY Owner C1 7>, & -4 S7; ifizAddress 6 F.-6.5.7 41;e:is y City ,..STe.c-Xt-t Zip Z.57 2.Phoneg.209-q3-Y-3 <br />C-57 Contractor Wood LA-) Address P x 33 e city!; 0 lASTc.„Zip '152/ Li c# 7 / Al "Iione# 7e.- 7 379- ii3c-C <br />Consultant / Sub Contractor /.2 if a_ El a "1.4 W-TchsldresS. 33,306—.4,-3,4 Pik acit<-4.5, PfLicit Phone# LC3z-) <br />GIS Coordinates: X Y Township Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED; <br />KNEW WELL / BORING ( CPT, GEOPROBE. HYDROPUNCH, HAND-AUGER, OTHER") <br />a SOIL BORING # <br />!KW ELL # 4,0 - p4 O.) 7 <br />'Other: <br />COMMENTS: <br />O DESTRUCTION (choose type below) <br />OVER-BORE <br />a PRESSURE GROUT <br />Grout Specifications: <br />C-57 <br />TYPE OF WELL INSTALLATION TYPE <br />gMONITORING AIHOLLOW STEM <br />O EXTRACTION a AIR HAMMER/DRIVEN <br />a VAPOR flMI,JD ROTARY <br />fl AIR SPARGE a PUSH POINT <br />U SOIL BORING a HAND AUGER <br />a OTHER: flOTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? El YES NO WELL CASING DIA: .2 f <br />CASING THICKNESS Se 4 q c) TYPE OF CASING: 11 STEEL At'VC n OTHER: <br />DEPTH OF GROUT SEAL ;C:- TREMIE TYPE TO BE USED: XAUGERS WHOSE <br />GROUT SEAL PUMPED: 3 Yes fl No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: Al a4.71- ce4.4 I <br />APPROX. BORING DEPTH SO KBOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? A-I ( 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 clone in accordance with San Joaquin <br />County Ord' nces, Rules and Regulations, and all applicable California State Laws. <br />Signed, — LA (4 Title/Company )f' Ii Eli V 4844 LC. <br />CLA'A ft4 cç" Date 1-1 1-0 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADD,ESS: <br />WORK PLAN DATED: <br /> <br />2/i <br /> <br />Print Name <br />Application Accepted By Date Issued <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />24-A7 Area <br /> Date Final Inspection By <br />COMMENTS / CONDITIONS 6--)e5a-wes/ 117. <br />ACCOUNTING ONLY: AID# <br />EAC <br />— <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE P_ERMIT—F-/Ell'EQ14.S„T# <br />_,,, -,..; --,-- 276.9' -7_9, //, / <br />' ''''),SR# c-r::, /6 vi S/''------ <br />WC -WAIVER C-57 Letter of Authorization to sign pertit.Encroachrnent doc 9/27/00 <br />TOTAL P.02