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04/20/2001 12: 54 209*433 FIFTH FLDORIP PAGE 02 q/ <br /> WELL PERMIT APPLICATION 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, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSULD <br /> Application is hereby made to Sen Joaquin County for a permit to construct andlor install the work described. This application Is made in compliance with San <br /> Joaquin County Development TiUe,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessors <br /> WELL Location --n F ^ 'i;' '• 21� Cross Street Ciry I fVtcY Zip 9.i ,9Parcel# <br /> PROPERTY Owner(C.c_::=ntcV I'Ty}9/ dress 3=ts�^lb4u 'I City i:• .;,.r.«r'r C!i Zp Phone# Z'Q7S'Z�' <br /> C-57 Contractor I— 1��,•��. Address R'c"rxZA ('+04'j City .^n:; = Zip"jS�(oio Llc#�Phone#S'a•-Jxjl 6'-14 <br /> Consultant � LiCrN la Phone#$ CC <br /> GI5 Coordinates:X ,Y ,Township Range See lon <br /> WORK TO BE PERFORMED: <br /> I EW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) p DESTRUCTION(choose type below) <br /> XSOIL BORING it z.4Q,C14 DOVER-BORE <br /> `OWELL# p PRESSURE GROUT <br /> 'Other: Grout Specifications: CSM E.n� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?O YES ONO WELL CASING DIA!- <br /> 0 EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER: <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: O Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or O STOVB PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: 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 that I have prepared this application and that the work will he done in accordance with San Joaquin <br /> County Ordinances, Rules and/Regulations,and all applicable California State Laws. <br /> Signedx V 1\ 'f.. Titelcompany <br /> PrintName i�v' '^"4 L1-+ FFtM- L, ih=--- <br /> Date <br /> �DEPARTMENT USE ONILfT J <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: L <br /> Application Accepted By Date Issued S r1)Jo Area <br /> Grout Inspection By ��r Date 2, A/ Final Inspection By _Date 7-� � <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY <br /> , <br /> PE CODES FEE NT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST R INVOICE <br /> C-57_ WCC WAIVER_ C-57 Letter of Authorization to sign permit,Encroachment doc_ 9/27/00 <br />