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10-24-2000 03 : 40PM FROr TO - 15306766005 P . 02 <br /> �� ) � '- � �F, ��-'% WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> OCT 2 4 2003 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> i _T�Ii ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> I . t al <br /> tl . . If, GI , LP <br /> � l <br /> �� FRfdi ! Tj� FP, 'a"ICES 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468-3449 <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 appllcallon 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 /> nn tf+� Lr I. Assessor• <br /> WELL Location 10% 26u fTC 5+• Cross Stree /1/� LA&I city 5Nvk ltA Zip Parcel# 1?3-130- D3 <br /> PROPERTY Owner f(e bZq -% /t�4 Address 701n5 Ar GT f7 Kitty ( ckl&'t Zip L � Phone6 do4- 431- � 0}0 <br /> C57 Contractor�2_ C� rjA rens � _rrJ sO 'I�%Q fn Yet/' CitKL (0015fcl Zip94$ � ,LicR�� Phoneme o} 3� y y3oo <br /> Consultant ] Sub Contmetor566 FAvIrqeyh 4T�� /WI Addres5333DCdr>teruytPulCP�� Sct,�tMyrr�n/< crew Phone#530476-2662 <br /> 95L$t <br /> GIS Coordinates' X.. Y . Township Range $6011011 <br /> WORK 706E E FO MED: - <br /> NEW WELL / BORING ( CPT, GEOPROBE. HYDROPUNCH, HAND-AUGER. OTHER') DESTRUCTION (chcose type below) <br /> 0 SOIL BORINO # \ 11 OVER-BORE <br /> If4NELL # W- /1 W NLW& - 18� VRESSURE GROUT <br /> ^Other; Grout S ocifications:_ <br /> COMMENTS' AG kR 41 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING JWOLLOW STEM DIA. OF BOREHOLESj MULTIPLE CASINGS? 0 YES ANO WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMERIDRNEN CASING THICKNES . yD TYPE OF CASING: 0 STEEL jl� VC II OTHER: <br /> MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE I. E SE t <br /> 0 VAPOR 0 k7 <br /> a <br /> E: MAXIMUM FREE FALL TH I <br /> ' 0 '^ .wa •i1 <br /> AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: <br /> ' Yes No ,(NOT <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: UM wv <br /> /- BOLTED TRAFFIC BOX or STOVE PIPE <br /> 0 OTHER:.a OTHER APPROX. BORING DEPTH VInu1C�L 0 <br /> " I ' - uv.� , I CONDUCTOR CASING PROPOSED? VW ( if YES, list specifications here): <br /> 'COMMENTS: <br /> l 'IAS {D I L� qL° ';s-- <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 /> 1 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. <br /> Signedx J(P'^' VAncS TitlelCompany ptd �� �5� - .s�f�t/VSrdyr�gr�T�+r•P''/ �riP <br /> Print Name stow 13lyk t'l Date ID- (, - D3 <br /> DEPARTMENT USE ONLY <br /> D <br /> SITE MAP IN UNIT IV FILE, A DRESS : Zo S O tnno, . S (c " r ' y <br /> WORK PLAN DATED : I�\ �t IUZ / <br /> Applicaflon Accepted By, CAMn ut' 6l h Date Issued .364 0 V Area <br /> Grout Inspection By., LAl4�Date O rinal Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID; s <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD 8Y DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3So ( g • oG ! I 3 Y o 3 -� 10 <br /> C-57_ WC=WAIVER—, C-57 Letter of Authorization to sign permit. Encroachment doc_ 9/27/00 <br /> TOTAL P . 02 <br />