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10-24-2000 03:42PM FRO TO 0 <br /> 15306?66005 P.02 <br /> ORIGINAL WELL PERMIT APPLICA ION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HT <br /> H SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DTVI ION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stocl�ton, CA,, 95202 <br /> (209) ass-3449 <br /> NON-REFUNDABLE PERMIT EXPIRE31 Y FROM DATE I SUED <br /> Application is hereby made b San Joaquin County for a permit to construct and/or Install the rk described. This application is made in compliance wirh San <br /> Joaquin County Development Tide,Chapter g-1115.3 and the Standards of San Joaquin Co my,Public Health Services,Environmental Health Division, <br /> WELT.Location 2 75 Pai'+f/5on �aM�Ond Cross Street'S� Assessafp <br /> G / tly j—__Zip Parcei# <br /> PROPERTYOwner Jr+M�Ja9�W14 dress Y CityZipPhoneS <br /> C-87 Contractor rilkA Addrass 550 -'Y01 Rd, City iii ks zip/DI Uc#71LU79 Phone#70�-.37y y3a�) <br /> Consultant/Sub Contractor EaY Lnt Address 330 City,S!&Ya/YIr,/�,I Lint Phone#�a-G7(.-��67 <br /> GIS Coordinates,X ,Y ,1)"v( ivik% Rane✓"1 �J�Z <br /> 9 _ Semon.33 <br /> WORK TO WELL <br /> E P MDQ k4� <br /> NEw WELL!BORING(CPT,GEOPROBE.HYDROPUNCH,HAND•AUGER.OTHER.) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# <br /> )KNELL# Z DOVER-BORE <br /> "Other: 0 PRESSURE GROUT <br /> COMMENTS: Well - GroutSpeeie dons: <br /> I` Ca 5 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATION ' <br /> XMONITORING ,'HOLLOW STEM . DIA.OF BOREHOLE 11.) i;-% M LTIPLE CASINGS?0 YES XNO WELL CASING DIA: /f <br /> ;A <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS$ ND H/( TYPEP F CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROl1T SEAL �mineATREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: `,$Yes No.(NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: A <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> l - CONDUC R CASING PROPOSE ?n (if YES,list specifications ere): <br /> 'COMMENTS: III pe i pIPGt'i «� �{� .I -Ns $P ai <br /> s od o �'n rr u 0 Zcvz 1. <br /> NOTE: OFFSITE BORIN S REQUIRE ACCESS R ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4$WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the war�C will be done in accordance with San Joaquin <br /> County Orr an¢es,�j and Regulations,and all applicable Califo is State Laws. <br /> Signed z__ G,CIA'6''�O/I V'� Title/Compan �o tai i 26,W77)/5},�s F- v. Tr, <br /> Print Name 5 Ldtt�7114i ' Dots 1-Z9-0Y <br /> DEPARTMENT USE NLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 257751�QUSc { �� <br /> WORK PLAN DATED: IS 0,`_tvbet 2007 <br /> Application Accepted Sy N Dace ssued 13&ri l �2P0H Area ill 5j <br /> Grout Inspection By Date final Inspection By Data <br /> Destruction Inspection By pate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECID BY TE PERMIT t SERVICE REQUEST# INVOICE <br /> 3501 003714 - <br /> C-57_ WC_-WAIVER—_ C-57 Letter of Authorization to S19 permit—Encroachment doc_ 9/27/00 <br /> i TOTAL P.02 <br />