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10-24-2000 03:40PM Fe TO • 15306766005 P.02 <br /> WELL PERMIT APPLICA ION 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, Stoc ton, CA., 95202 <br /> (209) 46834491 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> App6oation is hereby made to San Joaquin County for a permit to construct and/or install the iworl described. This application Is made in compliance with San <br /> Joaquin County Development Title,IC-hapter 9-111f5..3 and the Standards of San Joaquin County Public Health Services,Environmental Health <br /> Division. <br /> WELL Location I PC0.t'+ i no It Cad Cross Strelet-590 ity 77� Zip Q'� �,Parcel# <br /> PROPERTY Owner II J on "'.1 u� Iddrres$ f- +rr City-" ZiP�u ry�{.Phoneg <br /> C-87Contractor 1 rC�llLin Address 550 1`•V'lJl i`d, Ciry jD�•S Zipy45�1 Uc#_ 10V19 Phone#701-.33V N3D0 ' <br /> Consultant]Sub Contractor JT2 E✓ry. �hj Address. 330 IMGW City�9m�Lida Phone#5�0"L 7�ZC6Z <br /> 0"VC "4 SSo "" /Aicl QSh&z seeuon �v�i <br /> GIS Coordinates:X ,Y ,TownShip Range <br /> YKHrSTRUCI <br /> WOR) TO BE a 'F 'p• ION(choose type below) <br /> NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER•) Q OVER-BORE <br /> n SOIL BORING# <br /> ]�VJELL# Z RPRESSURE GROUT <br /> 'Other; Grout Specifications, <br /> COMMENTS 45%;A\5 Adblic <br /> .>1tGrC.vv1!'�t•N/fir <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a'tvbONiTORING ,HOLLOW STEM : DIA.OF BOREHOLE Io 'n M .LTIPLE CASINGS?DYES (NO WELL CASING DIA: <br /> ,4 <br /> 0 EXTRACTION II AIR HAMMERIDRNEN CASING THICKNESS5r A,Nfl PdC�. TYPE?, <br /> CASING: D STEEL J(PVC Q OTHER: <br /> 0 VAPOR 0 MUD ROTARY � DEPTH OF GROUT SEAL d 1 t�+^�'-TREMIE TYPE TO BE USED: Q AUGERS d HOSE <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'RyesNO.(N[OTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING OHANDAUGER GROUT SPECIFICATIONS: Mh AT(6t>iIa'1 <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 111) -"- .CONDUCT (if YES,list specifications here):-- --H--1 <br /> � i I n /r,'G1i •a.cZw� � !4 � - ,' � nc 5? Glc{�(,. /�Yr, <br /> 'COMMENTS: <br /> aria, a sir rt <br /> NOTE: OFFSITE BORIN S REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT AVIV 48 WORKING HOURS IN ADVftNCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the w4 will be done in accordance with San Joaquin <br /> County Ordinances, 1 and'Regulations,and all applicable Califs, nia State Laws. // <br /> 5 TitielCompanI 6,eo1ai 4 (96,7y77) 5 4jbChv, K<, <br /> Signed x C <br /> Pdnt Name ✓cd ��. Date <br /> DEPARTMENTUSE LY�� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 257'5 {�xQuSc <br /> WORK PLAN DATED: 15 0G -Aa 200 2 <br /> a l J 13 Rgr l 2&C { —Area.- <br /> j", ea 1453 <br /> Application ACCePted 8y Jy` z.(.5G✓\ Date{ssued <br /> Grout Inspection By <br /> pate Final Inspection By Dare <br /> Destruction Inspection By Data <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMrrMD CHECK# RECD 8Y p.�TE PERMIT I SERVICE REQUEST# INVO' <br /> 3501 NAW.. # fs17 5'+y <br /> C-57_ WC=WAIVER„•._, C-57 Letter of Authorization to sign permitT Encroachment dos_ <br /> TOTAL <br />