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02/13/2001 88:36 2094683 FIFTH FLOOR U I b+NAL <br /> _ ED WELL PERMIT APPLICATION FORM . <br /> SITE <br /> OCT 2 /'_ Z001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL'HEALTH DIVISION (PNS-END) UNIT IV <br /> H 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> - ..r. ..S (209) 468-3449 OrF <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C 5 <br /> Application Is hereby made b San Joaglrin County fora Permit m corutmct and/or install the 1vOrk described. This application b 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 Dh4slon. <br /> WELL Location Lofo. Ke t N� c}IL SlTee-'(} Cross street IF Abe r� dy S ck.�-. Assessor's <br /> PROPERTY Owner Ci}y of Sk->cicl...� <br /> c_ ,_Address C �P Parcel#City Zip Phone# <br /> C-v Contractor : cx k-- ay4--E'Address <br /> City S}gt]c� Zip LidF51226 8 Pnone# <br /> Consultant/Sub Contractor C.Ii_Zt'�9 1411L Address IS5 (�reA� Ave. City bo.kdn2 Lic# Phona#(slo� -221-2-ESF <br /> GIS Coordinates:X .Y - ,Township Range Seddon <br /> WORK TO BE PERFORMED, - <br /> �RNEW WELL I80RING(CPT,GEOPR08E,HYDROPUNCH.HAND-AUGER OTHER') p DESTRUCTION(droose type below) <br /> 0 SOIL BORING# <br /> %If WELL# 12.13.14 _ [1 OVER-BORE <br /> -�: 0 PRESSURE GROUT <br /> COMMENTS: - 21� fot(tSPednrations:_cevwn.�_hubNl� ra <br /> —s M <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,dMONTTORWG HOLLOW STEM -DIA.OF BOREHOLE—V MULTIPLE CASINGS?8 YES AND WELL CASING DIA:a f <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL `J(WC 0 OTHER <br /> 13 VAPOR 1)MUD ROTARY DEPTH OF GROUT SEAL 4 C 1 TREMIE TYPE TO BE USED: ]]AUGERS q(HOSE <br /> p AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: p Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I)SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> 13 OTHER: U OTHER APPROX.BORING DEPTH O `BOLTED TRAFFIC BOX or n STOVE PIPE ! <br /> CONDUCTOR CASING PROPOSED? tv-o (if YES,list specifications here): <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNH'IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify t t 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin es,R le an ulations,and all applicable California State taws., <br /> Signed ` 1 TidelCompanyPrint Name L-Vcfl1S�U.�/�r pate tola3l�) <br /> DEPARTMENI USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDS : <br /> WORK PLAN DATED: � d <br /> Appllration accepted By Date Issued /O - Q a O� <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 0ACCOU;NTINGONLY: AIT# <br /> FEEINFO AMOUNTREMRTED CHECK# REC'DRY DA7 PERMIT/SERVICEREQUEST# INVOICE <br /> V bZ <br /> C-57_ WC_-WAIVER C-57 Letter,of Authorization to sign permit_Encroachment doc_ 9/27/00 <br /> t <br />