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Ii <br /> J^ 10-24-2000 03 : 43PM FROr' TO 15386766005 P . 02 <br /> 1 <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 /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This applIcatlon Is made in compliance with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Publlicc Health Services, Environmental Health Division. <br /> ' f ` , ( I i j tySla f� fv'A Zi na. ,assessors <br /> WELL Location ��"I�`�r�Qrtlpi��I��TI�f'E'C CrosslJSftreeCt j1�'lj1 ,r� Sj II . _Ci I.- I ,l pJ p�;�f'7 _Parcel# 15.3 - I.30'I rL' <br /> PROPERTYOwner O �,{ pn * Address 1 71+ 1 I ioilQ55 Lalg (City . 11 rbY'i Zip JI�Js16 Phone!; �i <br /> C57 Contractor lif l i `i�tn' 1'IItv,Jlii(n' Address 60 I1Vik Pt�.. I , ( JJ City 1k�11,1 Zip qOj Lice lu I 'p Phonea a5S iLJ'5WO <br /> Consultant ! Sub Contractor J'1/0.1Uj CAVI rCL1 ytttNh�liTri AddreSsil'� IIA'n?/%1'I( �iX i/� , }7 yCity�N1' GN �M/ Lia: Phone# l.�'� �G' uA11 <br /> GIS Cowdinatas: X., Y , Township Range Section <br /> WNEWORK TO BE PERFORMED; <br /> WELL ! BORING ( CPT, GEOPROBE, HYDPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br /> SOIL BORING # tet' I — 2 J] OVER-BORE <br /> 1] WELL # n PRESSURE GROUT <br /> 'Other: Grout Specifications: . <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1] MONITORING p HOLLOW STEM . DIA. OF BOREHOLE P" MULTIPLE CASINGS? N YES 0 NO W ELL CASING DIA: <br /> (I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL rl PVC 11 OTHER: <br /> a VAPOR 1] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS d HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: KYes p No .(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 1] HAND AUGER GROUT SPECIFICATIONS: <br /> (] OTHER: `tOTHERCL APPROX. BORING DEPTH I I S � _ _- [] BOLTED TRAFFIC BOX or D 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 /> 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 /> e '. nIL '� <br /> lL Titie/CompanySi <br /> Signed 042 5 �* 7r"�t (/"ifiyLG5�57L TG JIL <br /> 5 .� N ✓I�drl /17P+vi�"� Z't , <br /> Print Name lot (S -Nwg Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED: h 1 L E e R <br /> Application Accepted By e� Date IssuedZI 'L'I O I Area <br /> Grout Inspection By v�yy\,c� Date 3 1z of Final Inspection Byto <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID,: <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK # RECD BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3s'ol ( . 00 ( 9�0 -6 (.LP z z( ol 0001� S 14 <br /> C-57_ WC=WAIVER_,,,_, C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br /> TOTAL P . 02 <br />