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3-- <br />WELL PERMIT APPLICATION FORM <br />AUG 1 6 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />orr?p,Ng-t) A <br />REC <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 />Assessor's <br />WELL Location 7-3 1639 s, &46-IcA r-e KdeCross Street City R.01et-60,it V..-- Zip 4S-SC7 Parcel# 2_49 -070-011 <br />PROPERTY Ownersluom RA nioj Address 2-23") -StrOlj Ave. City Gg6_600,1 Zip 41S-320Phone4,243-g-1so3 <br />C-57 Contractor G re55 lk nj Address 1S-0 40,4re RA_ City tAartitvzzip 9,-1z3Lic#9isi6s- phone#(42,43i3-&-k) <br />Consultant I Sub Contractor Se'COQ. $-INAertv4"1:‘ Aoll Address 30(7 16; tyLf.E. sie t c8tytaa,,d,0 coshi5t 6i z phone#hik) eci -04-100 <br />GIS Coordinates: X Y , Township T,SC, k.,1'‘N Range Section E.-ZOLS Section LI <br />WORK TO BE PERFORMED: .5-) <br /> <br />NEW WELL/ BORING ( CPT, GEOPROBE, H D-AUGER, OTHER') 0 DESTRUCTION (choose type below) --)•) <br /> <br />%SOIL BORING DOVER-BORE .6--- <br />a WELL # a PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 22 MULTIPLE CASINGS? 0 YES a NO WELL CASING CIA: <br />[I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC [1 OTHER: <br />1:1 VAPOR [1 MUD ROTARY DEPTH OF GROUT SEAL 6S-/ TREMIE TYPE TO BE USED: 0 AUGERS WHOSE <br />O AIR SPARGE XPUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') R <br />%SOIL BORING ri HAND AUGER GROUT SPECIFICATIONS: <br />[] OTHER: a OTHER APPROX. BORING DEPTH iS 5 / [] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />COMMENTS: <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 d Regulations, and all applicable California State Laws. <br />Signed x a-LISC Title/Company ..SF..-CC; ...f.A.elrtektt+10AcA I <br />Print NameJ (ff-- Aucv.i--er e Date 411° <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br /> <br />23569 s <br /> <br />IPCI t <br />Final Inspection By: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS <br />Date <br />Date <br />4•40C2011114 <br /> Area 0629 <br />Date 724 -C 2 <br />Date Issued <br />i ACCOUNTING ONLY: AIDS* <br />FAC# <br />PE CODES FEE INFO AMOUNT REhliTTED CHECK # RECD BY DATE ' • lik: INVOICE <br />IS0) Vit ' DO,DI o 1 -C g-elR#02-7- &01 <br />C-571 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />croachment doc 9/27/00 <br /> <br />CO 39t/c1 <br /> HI__dI <br /> EEVE89176K <br /> Is :ET 000Z /170 /Z1