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10-24-2000 03:40PM FR❑r- T❑.. ..: 15306765005 P.02. <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES M[TiGATION. <br /> t 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 /> Apprication is hereby made to San Joaquin Codnty for a permit to constructand/or install the work described. This appflcation Is made in compliance with San <br /> Joaquin County Development Tiff e,Chapter&1115.3 and the Standards of San Joaquin County Public Health Services,Envimnmenta(Health Division, <br /> ' Assessors <br /> WELL location &A r e��L' %577+e e* Cross Street ! ..tia 6!City .S Zr,L.c Zip_gr2o Z Parcel# <br /> PROPERTY Owner C,,7 v crf !� Address IV. �lQrq�Q s�� Citycr �Zipj!Z2oZ.Phonez;Z O? U2L 8L3 <br /> C570ontractor codw�.s�l f�i�Er dress PDaox 1.331xP99a_ueQ*,,n Phone;707c371E-ff3c)e; <br /> Consultant/Sub ContractarVG 40r���tttT dress ka city".A Lim Phone#cSSoG7[ x,60 <br /> GIS Coordinates:X Y Township Range_ _ Savion <br /> WORK TO BE PEPF 1? <br /> 0 NEW WELL!BORING(CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') d DESTRUCTION(choosetype'belaw) <br /> SOIL BORING# Il OVER-BORE <br /> WELL# /h11 „_ _ PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING $HOLLOW STEM , DIA.OF BOREHOLE 9 MULTIPLE CASINGS?13 YES e,<NO WELL CASING DIA: <br /> a EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS S,4 �U TYPFOF CASING: 0 STEEL IrPVC -13 OTHER:_._ <br /> [[VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL - 4W W TREMIE TYPE TO Bi USED: *AUGERS 0 HOSE <br /> 1]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: VYes *o.(NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Al OZr <br /> 0 OTHER: 13 OTHER APPROX.BORING DEPTH Q . iBOLTED TRAFI=IG BOX or 0 STOVE PIPE <br /> /� <br /> CONDUCTOR CASING PROPOSED?__AeLa (if YES,list specific�Gdns here): <br /> 'COMMENTS: /�- �e_-L <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 /> t <br /> { <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance R es and Regulations,and all applicable California State Laws. <br /> Signed x 6 Title/Company_S Tyr 6,00j-01 Z oe)A �a✓i!�'nl7r��/��.r. <br /> Print Nam SILT �' }t 1'� Date__`r7___ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 32-12 l <br /> WO' RK PLAN DATED: ?11214e <br /> Application A=epled B 5 <br /> Y _- � -- -- �[ Date Issued L0 DArea <br /> Grout Inspection gy Dats i incl inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS t CONDITIONS: S CG co <br /> ACCOUNTING ONLY: Att7# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECO BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 3!50 f 37 %b 00 7.6 7-7i4 <br /> C-57_ WC,_,,,,,Y„-WAIVI=Rr,,,_, C-57 letter of Authorization to sign permit Encroacht�ent doc_ 9/27/00 <br /> TOTAL P.02 <br />