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10-24-2000 03:40PN Fa TO 0 15306766005 P.02 <br /> WELL PERMIT APPLICATION 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) 458-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appgcation is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application 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 /> �t ff }}��- /�,.,, T Assessors <br /> WELL Location dtj7�h)p oR�LlfA� ct/ i4 CCross Street Lh`�d City T1'z Zip Parcel# <br /> PROPERTY Owner <br /> pp fiI\]A� 7 //�� Address (,'" ii` P City Zrzip Phones <br /> C-57 Contractor W5 illi W, Address U Ci V Zip�Ue#7/Cot) Phone#;b7-3'p/-4 o <br /> 5{ti 'S EAV., �^[. 33'3J G11,zwI, Ur, 6lCL{G( f5[y� Phdne#53/1 <br /> Consultant!Sub Contractor Address_ _ City Os <br /> GIS Coordinates:X ,Y ,Township—T15 15 --�— Range 1\N Se060n <br /> WORK TO BE PERFORMED: <br /> R NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNOH,HAND-AUGER,OTHER-) DESTRUCTION(choose type betow) <br /> o SOIL BORING# ;(OVER-BORE <br /> WELL# <br /> ,Other: 0 PRESSURE GROUT <br /> COMMENTS: Grout Specifications: <br /> Or.II , cfa�rwu u <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 17 MONITORING AHOLLOW STEM DIA.OF BOREHOLE10 "T MULTIPLE CASINGS?R YES 0 NO WELL CASING DIA: 1 <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 9 STEEL XPVC BOTHER; <br /> '24/APOR Q MUD ROTARY DEPTH OF GROUT SEAL q, TREMIE TYPE TO BE USED: Q AUGERS a HOSE <br /> 0 AIR SPARGE ()PUSH POINT GROUT SEAL PUMPED: Wes aprN,o�(NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> d SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS: YlyitT dryu,4 <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH c] ( II BOLTED TRAFFIC BOX or U STOVE PIPE <br /> D6110,1 <br /> ,,gg++ CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: +//IIIO,1 ty'LL1 Vw.Iti ' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR 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 work will be done in accordance with San Joaquin <br /> County Ordiinlan es, Rules and Regulations, and all applicable California Statte�Laws, <br /> Signed x� ''t1pV'�`7 Title/Company (;YGu,�j i Sfs/i!S �i1V Tt/c, <br /> Print Name s(i4 B;ffi.,gn Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z5775' S. hL+eCsGn 55 t�d . <br /> WORK PLAN DATED: ,1 I S 060 ea ZOU <br /> Application Accepted By Iy�C( Ek)CrCo- — Date Issued 13A-t1Aa UUYA ea 11:53 <br /> Grout Inspection By. Date FinalInspection By Pate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECKS RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> X50 z �c �0 5vy�i1 CIu7-/C 007143 <br /> C-57_ WC=WAIVER,.,,_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br /> TOTAL P.02 <br />