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10-24-2000 03 : 43PM FROP TO -- 15306766005 - P . 02 <br /> n <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC , ] IrI1T tV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS -EHC � " <br /> 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468 .3449 MAI' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> Application is hereby made to San Joaquin County for a permit b construct and/or install the work described. This apph'C�dti'on -Ismade in compliancy with San <br /> Joaquin County Development Title, Chapter 31115.3 and the Standards of San Joaquin County Public Health Services krironmeDLl N' i slvision. <br /> �p y� / 5.�, City tkk ZiP Parcel# oI <br /> WELL Location �� � � 5'I FY2ir-rw15}' I Cross -e <br /> ,lnZV I�t'I <br /> PROPERTY Ownler,/�Y�✓n4r �k7tii JMv�fI 't�l Ad�dre55 ! U)-�/ y�L"+c'✓1 GT p City.Sror�{aYl Zip �Phone# 0�0 `� =�31'7�'7U <br /> C.57 Contractor W C 1 n_J Ii^ to Address .lJ0 RO/LI &I CityPi c ViSlsl _ Zipj � / UCm W Phone#J 7-3rL'YYU <br /> Consultant ! Sub ContracfnrS4i l.?IJ; FNy , ( Address3L)l 5cityv'2au I'� i ���'� L Pncnea3P -E7E - 2r,�t: � <br /> GIS Coordinates! X , Y , Township Range Section <br /> WORK To BE PERFORMED: <br /> [] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') EXTRUCTION (choose type below) <br /> 0 SOIL BORING # ` o OVER-BORE <br /> I] WELL # ill <br /> / PRESSURE GROUT <br /> 'Other; . Grout Specifcations:�; / <br /> COMMENTS' zeir:aJ MLU IZ - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `'MONITORING o HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? YES Q NO WELL CASING DIA:_ <br /> Il EXTRACTION 1] AIR HAMMERJDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL [I PVC I) OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: d AUGERS 0 HOSE <br /> US <br /> o AIR SPARGE f) <br /> PUSH POINT GROUT SEAL PUMPED: DYes p No .(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> • <br /> f] SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER U OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> "COMMENTS: 0?7 5v �. � ' p ;,� � �;, ,,� "1 — <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 Orrddinaanres, Rules and Regulations, and all applicable California State Laws, <br /> Signed 4 I� � Title/Company 7� 7T &J, e7,, -, <br /> Print Name Stt / Date - y -�a <br /> DEPARTMENT USE ONLY � � F.), <br /> SITE MAP IN UNIT IV FILE, ADDRESS : �o50 � VAV IaJ 5: 1 �(`,+j <br /> WORK PLAN DATED : <br /> Application Accepted By. fLNwAAC Date issued O Area Z <br /> Grout Inspection Date C� Final Inspection By �Date `/ . <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3 ! 1 4. croo SSS`( Y o 3 p4m 1 <br /> C-57_ WC_-WAIVER„_„_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br /> TOTRL P . 02 <br />