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10-24-2000 03 : 40PM FRO^' TO 15306766005 P . 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA. , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applkatlon 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 /> _ I �. 11 �� II � [[ Assessors <br /> WELL Location � 5 _ � . rl- ✓1t1 *, ,�� 5 �% � f Cro 'ss1 �Street <br /> bli^ZI . CIIYS6klc�� Zip( 51055 Parcel# M4 113- I�I <br /> PROPERTY Owner r"-,ll� rf 'Shav JE' r Addresa_l a.'? 1-, J1671 Lw� CityS „il h Ziprsl 217 Phone# <br /> T 1 � � �� �" 15 Pnone#`(35313 -53 U <br /> CS7 Contractor fQ � � r 'l��.n" �11�Srf" AddresISO .9 ls n„ IZr�. _ Clityn � Zip�l� 4�� LiC"r r / � , <br /> Consultant ! Sub Contractor J ' ruILS I-r1v" + a1il' �nIAA')�N(,Adtlres53-5 ( Gy1N1 •NI'aI rV IJ! ' CitywttltaH i Lic# Phone# 530"6 7b boCq <br /> GIS Coordinates: X , Y , Township Range _ Section <br /> WORK TO BE PERFORMED; <br /> `(NEW WELL ! BORING ( CRT, GEOPROBE, HYDROPUNGH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> If, OIL BORING # CPT� I DOVER-BORE <br /> p W ELL # n PRESSURE GROUT <br /> *Other; Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING n HOLLOW STEM DIA. OF BOREHOLE l ` MULTIPLE CASINGS? p YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC n OTHER: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: Wes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> n OTHER: OTHER APPROX. BORING DEPTH I I S t _— n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 11 CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> 'COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALLTHE 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 /> Title/Com n S .u�a4 . 1 .5 /a6FVIVinyl M N �' � L <br /> Signe� x / L (7Wt^Mf ►a y <br /> Print Name C-/CA 1 � 1J i IL� t nr Jr Date, JO <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> Application Accepted By ''' ��, ��� ''' ��/ ___ ''' Date Issued ZI Z--I b/ Area <br /> Grout Inspection By Date Final Inspection By hI �g se.-!iceDate <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECO BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> V � _ 00 ( e0.6 p � s <br /> C-57_ WC=WAIVER,-,_-_, C-57 Letter of Authorization to sign permit. Encroachment doc 9/27/00 <br /> TOTAL P . 02 <br />