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NOV-21-2001 15:10 JEOMATRIX FRESNO 559 264 7431 P.04i12 <br /> ' r <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) 468-3449 <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> N w. o f C.er rAA 40II ew Rd•€ �x rpt >�.;N� city Tmfa M Zip Parcel sots <br /> WELL LoeaUon Cross Street <br /> PROPERTY OwnerC,ordoza �xWQIYt76S Addre55 1111 Grce_er.IStq.6 yCityn!ANt CM1LZip ` 5 vhone# Xr-- 32- <br /> e" <br /> C-57Contractor Spdefi"I`1M IPAAddress 2365 W;jtVAvZipq520sLIc#5116t <br /> phone#���I-�4b5^8�t2 <br /> Consultant/Sub Contractor(404PAAtnx C&A1`lt1"�SAddress 2444MAin e-t-z ,te.215City 4i-Av tic# 01450 phone#W-264'25$5 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: f <br /> p NEW WELL/BORING(CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER") /Od /DESTRUCTION(choose type below) <br /> Q SOIL BORING# OVER-BORE <br /> Q WELL# [)PRESSURE GROUT <br /> `Other: Gro Specifications: eaut bo�•�o>nir�^[CtMQln� <br /> COMMENTS: 2 w s : MW-10 . MW-14 "� 4 , Ire drf ve - 26 sec A *d rita <br /> o w i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONS IFI AT NS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE fL D� MULTIPLE CASINGS?AYES /0 WELL CASING DIA �t rt <br /> p EXTRACTION a AIR HAMMEWlDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL )ePVC a OTHER: <br /> D VAPOR 17 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: d AUGlrRS Q HOSE <br /> B AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: Q Yes I1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I)SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: a OTHER APPROX.BORING DEPTH 24 r BOLTED TRAFFIC BOX or 17 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? WA (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 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance , Rule !nRequlatlons,and all applicable California State Laws. /+ <br /> Signed x Tille/Cornpariv <br /> Print Name V ff.," C& �� ' f•E• Dato <br /> DEPARTMENT USE ONLY 7R <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ___ /,/ry 1 c <br /> Application Accepted By Date Issued " !� T Area 4 - <br /> Grout Inspection By Date Final Inspection Q;y,.F c. " Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FArV <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> D /007,7'7oW - i 8rz <br /> C-57 WC -WAIVER_.C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />