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10-24-2000 03:40PM Fie TO • 15306766005 P.02 <br /> WELL PERMIT APPLICA ION 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 YEAk FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vrork described. This application Is made in compliance with San <br /> Joaquin County Development Ti ChaS- 1 t5.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> WELLI.oceton2bl�� 5, �a CrossStreet-.�'%C Assessors <br /> � / 'r4,tlitly aG 1� Zip Parcel# <br /> PROPERTY Owner VI 4[/A I/1/S"f Address_ �I31 nU/0 "c4.`,T`aA 'YA City ��j4+1 Zip Phone# <br /> C{7 Contactor At9 Drllll [c Address)/0 �IVGI l�^r+t/ City'. I0 Ui / zip//y1S/ll uc#71oo1 PnoneR�70i7 ��. <br /> Consultant/Sub ContractorSTzg, FA, �kc, Address ;� s� It waKAc �' city(ArHC1�11!"�yC Liek yS6�L Phone# JpO-67erZUGZ <br /> GIS Coordinates:X ,Y ,Township T,�S Range Rye Semon <br /> WQRKTO BE PERFORMED; <br /> EW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# a OVER-BORE <br /> WELL# Z. 0 PRESSURE GROUT <br /> "Other) Grout Speci Pons: <br /> COMMENTS: J7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATION <br /> A(MONRORING `, _HOLL.OW STEM DIA.OF BOREHOLE 10 �m_MLTIPLE CASINGS?11 YES ,Q NO WELL CASING DIA: <br /> 11 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS5c 40TYPE/OF CASING: 0 STEEL kopVC a OTHER: <br /> d VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL be CG' ir'-I TREMIE TYPE TO BE USED: G AUGERS 0 HOSE <br /> a AIR SPARGE o PUSH POINT GROUT SEAL PUMPED: (Yes 4r[t No ,(NOTE: MAXIMUM FREE-FALL DEPTH 1130') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: nR4 derV } <br /> la OTHER: Q OTHER APPROX.BORING DEPTH 1 10 14d )tbOLTED TRAFFIC BOX or a STOVE PIPE <br /> III C NDUCTOR CASING PRpPOSEp? 40 (if YES,list specifications h�e�re): <br /> C M ENT - W0S U I1 b( i�tShtb ✓rtmyc/i.a"��"" Qd1, t -� fo Mu4/2) i 5, I bo,'ma (Seda A4i APP,nG7Xyl I oT o Le <br /> IaIJ/'m1h Y15as7ilut4' Sq dGloix-I5,ZcOIL wt lc <br /> NOTE OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADV CE 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 Ordi ances/, Rus andRegulations,and all applicable Callfo la State Laws. <br /> l �/ <br /> Signed x__ _../✓r'"' Tito/Company "�/r Yj ` ,6.-7y-/ /54y46 Fy, i�<, <br /> Print Name JLd 4 R�Aif L Date EZ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ _ 25--175' S, ��iTTef 1 Tks, r <br /> WORK PLAN DATED: \ IS 0CC4C'L '­ ZOOZ J <br /> Application Accepted By �uZ( ��"e�Jer«.� Datessued t)Issued 3/Cy Area /rr53 <br /> Grout Inspection By. Date Final Inspection By Dare <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# RECID BY OTE PERMIT I SERVICE REQUEST# INVOICE <br /> 3507 Mw 9 1 5` ;5'v co 1-/( 1 jsR9 0037044 <br /> C-57_ WC -WAIVER,-_ C-57 Letter of Authorization to sig'permit—Encroachment doc_ 9/2 <br /> TOTAL P.F <br />