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09/20/2000 14:04 2094662433 FIFTH FLOOR <br /> PAGE 03 <br /> 0 to <br /> WELL PERMIT APPLICATION FORK! 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 Tulle,Chapter 9-1115,E the Standards of San Joaquin County Public Health Services, Environmental Health Division, <br /> WELL Location_ SP,�EC,CELS Sov �eg,Up�L' os street coiP,2gLfibc(Ai,JC;tyr j/zI Zi Assessor's <br /> --, P Parcel# <br /> PROPERTY Owner S ECeEL5 Sv A2 CO. Address 20,560 //,lleee-y e>?. C; �� <br /> tY���_Zp t53J6 PhonefF�Lo9�83S-3L�$ <br /> C-57 Contractor_ CASe,41JA<e Address 3032 c &e, p 9y7VZ Lic# / S 0 Phone# <br /> Consultant/Sub Contractor__ ?5'K 4,550 Address Goch C,4�y�RQCi <br /> ry����(dLic# Phone#�y/6�BS3-9Z'3j <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED- <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER`) o DESTRUCTIONchoose <br /> p SOIL BORING# ( type below) <br /> `Other A WELL#_ 8 W-� (�. 1]OVER-BORE <br /> [] <br /> GROUT SPECIFICATION PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> /MONITORING ,HOLLOW STEM DIA.OF BOREHOLE /D„ MULTIPLE CASINGS?U YES INC WELL CASING DIA: fe-- <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 5eRt z/-0 TYPE OF CASING: Q STEEL I PVC [i OTHER: _ O <br /> O VAPOR p MUD ROTARY DEPTH OF GROUT SEAL X0 &TREMIE TYPE TO BE USED: N AUGERS []HOSE <br /> 0 AIR SPARGE j]PUSH POINT GROUT SEAL PUMPED: p YeNo s <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATION 5�c �N �MAXIMUM FREE-FALL DEPTH IS 30,} r <br /> 0 OTHER: 1]OTHER APPROX,BORING DEPTH—15- 1!BOLTED TRAFFIC BOX or O STOVE PIP <br /> ES <br /> CONDUCTOR CASING PROPOSED? ES (if YES,list specifications here): c,,�RP62 49 <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> 'ounty Ordinances,State Laws,and Rules and Regulations of the San Joaquin County. <br /> *C L TAN I INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> )Igned x 1 <br /> Title/Company d Cas eat cy/� <br /> 'rint Name r M Date '- .2.2-q - 06 <br /> SITE MAP IN UNIT IV FILE ADDRESS (WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> ppllcation Accepted By Dace Issued O d Area (L/ �/� <br /> rout lnspecticn By (,d- o Date !1 13 b0 Final Inspection By Date , <br /> estructlon Inspection By Date <br /> OMMENTS/CONDMONS: Imo,) W t <br /> ACCOUNTING ONLY: AID# <br /> FACA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 15139 <br /> 1a- <br /> P_F7 <br />