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. <br /> 1,. 10-24-2000 03.*40PM FROM TO 15306766005 P.02 <br /> Alwr <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON•REFUNDAR1.E 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 appllcadon 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 /> WELL LoeatEon { - Asse56orS <br /> _i7!.l�.A 6Gross Street Ce-le'Forki4.City Zip g3�0ZFarcet# <br /> PROPERTY Owner C+71 . hCity_, loe/ o-1 Zip <br /> 9SZ4LPhoneu204�r3T�8��j <br /> C�57 Contractor w po d WnnC-/ri,� Address PD� ,X 3 3 City T Zip �/ �Lire Dal one# �O� ,37�/"y3p0 <br /> Consultant!Sub Contractor A/G f F dro-PA,rrr dress,3s3�-DCa a�o�+P.NQ.Eit7G+•e.e i PhoneiY Sc Q G Ae-CCo0 <br /> GIS Coordinates,X _'y Township Range_ Semon <br /> WORK TO BE: pE O D• <br /> EW WELL!BORING(CPT.GEOPROSE.HYDROPUNCH,HAND-AUGER.OTHER-) a DESTRUCTION(choosetype'below) <br /> [1 SOIL BORING# 0 OVER-BORE <br /> WELL# M W- (o M LO ?_ 1]PRESSURE GROUT <br /> lothar. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]KMONITORiNG XHOLLOW STEM DIA.OF BOREHOLE 97 MULTIPLE CASINGS?ll YES �NO WELL CASING DIA: _L <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sc� YO TYPE OF CASING: 0 STEEL &,I'VC a OTHER_ <br /> Il VAPOR p MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: )*UGE;RS "OSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes I]No .NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL,BORING Q HAND AUGER GROUT SPECIFICATIONS: NaZr Ga.We 4 r <br /> a OTHER: n OTHER APPROX.BORING DEPTH 90 KBOLTED TRAFFIC BOX or a STOVE PiPlr <br /> // CONDUCTOR CASING PROPOSED? w.r O (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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' .5ncces, Rules and-Regulations,and all applicable Californiiaa,State Laws. <br /> Signed �t 5 Title/Company I.ft'_�k - <br /> Print Naive t <n ?,, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE=,ADD SS: /Z S51'. <br /> WORK PLAN DATED: W* <br /> Application Accepted By i Date Issued �J�7/0 Area <br /> Grout Inspection By_ _ Date Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID`n <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3z-7y6 q �s/� SR#e571-OZ6 <br /> C-57_„ WC=WAIVER C-57 Letter of Autharization to sign permit Encroachment doe 9/27/00 <br /> TOTAL P.02 <br />