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11/08/2001 14:37 209-579-0?25 MODESTO ATC PAGE 02 <br /> *Awl <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 /> NO REFUNDABt PERM►T EXPIRES 1 Y R FROM DATE 1$$m application is made in compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work d®scribed, This app'h <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Assessor's <br /> Health Services,Environmental Health Division. <br /> ClParcel#, <br /> t}VELL tocatlon•� I�J 2 �� �f a rd i✓� W°; Cross Street �5&C <br /> ty- y✓2—Mp <br /> a/ , O city P4dz9.s& <br /> 1p ,Phone#_ - -s <br /> PROPERTY Owner dress <br /> PD Box3 city zip Sz uc# ro Phone# - <br /> C_57 Contractor /v A�,r�� ddresa_ <br /> (/ tlt� !.n i Po�lm g City di�SfD Lic# Phone# s <br /> Consultant/Sub Contractor Address_, Af- �--- <br /> GIS Coordinates:X <br /> Township_ Range Sermon <br /> fR1 <br /> PERFORMED: 0 DESTRUCTION(choose type belcW) <br /> EW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTIiER•) OVER-BORE <br /> U SOIL BORING# 0 PRESSURE GROUT <br /> WELL# Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t l <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE____r��_,4 MULTIPLE CASINGS?U YES KNO WELL CASING OIA:�_ <br /> p EXTRACTION (i AIR HAMMER/DRIVEN CASING THICKNESS._ �7'TYPE OF CASING: []STEEL VC OTHER <br /> Q VAPOR U MUD ROTARY DEPTH OF GROUT SEAL_f� TREMIE TYPE TO BE USED: a AUGERS d HOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 1((es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: yw KA roe <br /> a OTHER:,_ n OTHER APPROX.BORING DEPTH5-01 Q�90LTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AJO (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 be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State//Laws. <br /> Signed x <br /> Title/company. /ZthGi^I <br /> J <br /> Print Name JCeA IZnJ✓ /I'1 Date., <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 l�' i '4-t C <br /> WORK PLAN DATED: (P 5 0 <br /> I O <br /> Application Accepted By JYY� � Date Issued [U ---Area—2 I-/—T- <br /> Grout Inspection 13y--JP4 e V4 Date l l l (¢j lar.(Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACU <br /> PE CODES FEE INFO A_ MOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> 1 1 L �� fl1glo IIARA2 0 O <br /> C-57 WG -WAIVER____ C-57 Letter of Authorization to Sign permit Encroachment doc 9/27/00 <br />