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��L D <br /> DEC 0 7 2000 <br /> ER'IRIaf-M`FNT MFai '` -- <br /> WELL PERMIT APPLICATION FORM 1WAT��§ftfFs <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH bIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEARFRQM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is r jade in compliance with Sar, <br /> Joaquin County Development Title,Chapter 5-1116.3 and t,..e Standards of San Joaquin County Public Hearth SeMces,Enviror rental Heal:h Division. <br /> Assessor's <br /> WELL Location T90 oekw- /ZC/., Cross Street city Z&1 zip _Parcel# L249'05-d3 <br /> PROPERTY Owner Address 14rz, tBarrr� City 0-"kW ZipjQIj Phone# <br /> C-57 Contractor I �C IA) Adcress IMO b""cJk f-M� CItLy�TS�G Z�p.S569/Lc#7La2 P^one ci(6L7�7'4/DO <br /> Consultant!Sub Contractor 4&Aj-,v/ZIR0 Addressl 7/S! ftia a6Td/ Clty�c�Lic# - Phone# M'S&� <br /> GIS Coordinates:X_.,_. Y ,Township Range Secticr <br /> W Rt TO BE PR- <br /> ) <br /> lE'W WELL BCRItFz P-,GEOPROBE,HYDROP H,HAND-AUGER,OTHER") -jESTRUCTIO`(choose type below) <br /> R-!5'CSORINIG# '7>/ " ,,VER•BCRE <br /> nWELL# L ,rRESSURE GROUT <br /> 'Other.Adylluem .e//� r Grout Specifications: <br /> COMMENTS: ' - - " � <br /> TYPE OF WELL INSTALLATION NSTRUCT N SPECIFICATIONS <br /> 11 MONITORING E<OLLCW STEM DIA OF BOREHOLE MULTIPLE CAS NGS7 OYES ONO WE LL CASING DIA: <br /> 1]EXTRACTION [,AIR HANIMER'DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL p PVC 0 OTHER: <br /> 11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /DU TREMIE TYRE TO BE USED,. 816GERS 0 HOSE <br /> 0 AIR,SPARGE n PUSH POINT GROUT SEAL PUVPFD: g-le's 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1115CIL BORING 0 NAND AUGER GROUT SPECIFICATIONS: /&[ <br /> 0 OTHER: —0 OTHER APPROX.BORING DEPTH /C20 0 BOLTED TRAFFIC BOX or 0 STOV=PIPE <br /> CONDUCTOR CASING PROPOSED? ( f YES,list speciBCations here). <br /> 'COMMENTS: <br /> OTE: 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 hatPT9VIAprepared this applica and that the work will be done in accordance with San Joaquin <br /> County Ordi n 3,R and Regulatio , nd all applicable California State Laws. <br /> Signedx. Tit,e/Company L<//> (X!��i►'lIU.CC! �C�(J <br /> Print Name A( '.L Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:L J // <br /> Application Accepted By& nns Date Issued th I n l Area <br /> Crout Inspection By Date Final Inspectlon By Date <br /> Destruction Irspecticn By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FArg <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> e) 3 ! t ul 00(0 <br /> C-57, WC_-WAIVER_. C-57 Letter of Authorization to sign per-mit—Encroachment doc_ 9/27/03 <br />