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1/13/2001` 08:36 2094633 FIFTH FLOOR �-4 PAGE 02 <br /> .w WELL PERMIT APPLICATION .FORM , <br /> l _ SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> I' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 0 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San JF <br /> Joaquin County DevBId�ma-st Title,Chapter&1115.3 and the Standards Of San Joaquin County Public Health Services,Env ronmenlal Health Divislon. <br /> v n� - 1�� Assessor's <br /> WELL Location-Pt". ( 4 rl h Dross Street VO'no -/nUA Oily Sh��k.I zip Parcel# <br /> PROPERTYOaner C r �) d / ..1�QdressCity lip Phone# <br /> I <br /> C-57 Contractor Address City. Zip Lida Phone# <br /> Consuttant/Sub Contractor CLrl M 1..11( I , Address-W Gll Anck AiA-t Clty_QUi r.a Lidi Phona# `IIOZ\V 11t? ev�-Z IDI <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> i <br /> WO K TO BE PERFORMED: <br /> f EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 13 DESTRUCTION(Choose type bek7w) <br /> 4 U SOIL BORING# ❑OVER-BORE <br /> p W ELL# PRESSURE GRpUT <br /> •ocher: Mdnl� rriyK �nea. . , Groutspeanrulions:rPlumprn�-hnml,MIN-o tw0ia <br /> COMMENTS: s <br /> 1TYPEICIF311MIAL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM 11p wet IA.OF BOREHOL r� <br /> ( F_ 6 „ MULTIPLECASING3711YES 10 WELL CASING DIh? <br /> 0 EXTRACTION B AI HAMMERJDRIVEN CASINGTHICKNESS E OF CASING: B STEEL OVC B OTHER <br /> B VAPOR IUD ROTARY (1u�1(� DEPTH OF GROUT SEAL f �7REMIE TYPE TO BE USED: B AUGERS ,NHOSE <br /> B AIR SPARGE `- 0 PUSH POINT GROUT SEAL PUMPED: )(Yes B No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> f 0 SOIL BORING B HAND AUGER GROUT SPECIFICATIONS: <br /> I 0 OTHER: 0 OTHERPPROX.BORING OF37}{ ^'I bb fV 1570 OfOLTEO TRAFFIC 80X or B STOVE PIPE <br /> t, P CONDUCTOR CASING PROP/OS5ED? A(S_(if YES,list specifications here): <br /> *COMMENTS:�W�'V `N (W I ( W`Id- ro LSO� W' 9�p STEEL CON0WIt"t- C#4-?t Nb TO 17.d/. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> ro CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I here fy that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> j CounOrdi antes,Rules an lotions,and all applicable California State Laws. /� <br /> Signedx <br /> Print <br /> r <br /> DEPARTMENT USE ONLY � <br /> SITE MAP IN UNIT IV FILE ADDRESS: I i O ✓`}— <br /> WORK PLAN DATED: l) 0 O <br /> Application Accepted By 0lot LQQL� Date issued 3 1) I �r ___ _ ea l <br /> Grout Inspection By Dale Final Inspection By - Da-�--a-ew�ww...Yr <br /> Destruction Inspection By Date ID 1r s 3 Z. <br /> COMMENTS/CONDITIONS: <br /> t <br /> ACCOUNTING ONLY: AID# <br /> - PECODES FEEINFO AMOUNTREMRTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 I YAW — o - OML- (v�3 <br />+i <br /> C-57 WC_-WAIVER_ C-57 Letter,of Authorization to sign permit Encroachment doe_ 9/27/00 <br /> 1 , <br />