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05/21/2001 07:23 2094671118 AGE STOCKTON PAGE 02 <br /> V �...I <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) - <br /> 304 E. Weber, Third Floor, Stockton, CA., 95242 <br /> (209) 46$3449 <br /> NON-REFUNDABLE P ERMIT EXPIRES 1 YEAR FROM DATE tSSUE <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 8-1115.3 and-the Standards of San Joaquin County Public Health Services,Irnvlronmental Health Divislon_ <br /> C Assessods <br /> WELL Location I� � n� Cross Street City np`.�3 Parcel#_r� p <br /> PROPERTY Owner r� Address City dt- Zip��Phonaoob I£2S <br /> C-67 Contractor <br /> Eli 11 Address City Zip LLlc#7 Phone# <br /> Consultant/Sub Contractor ��6 Address QS? S � city 1� LIC# Phone# �_ �1 <br /> GIS Coordinates:X y_,Township Range Section_._ <br /> W K TQ BE PERF aMED: <br /> EW WELL I BORING(CPT GEOPROBE,HYDROPUNCH,HANC7-AUGER,[)TREK'} DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> 'WELL l,�4 _ �PRESSURE GROUT <br /> 'Other' Grout Specifications: <br /> COMMENTS: <br /> TYP OF WELL INST TION TY CONST CTION SPECIFICATIO <br /> O MULTIPLE CASINGS? I YES Q NO WELL CASING DIA-.2 ' <br /> ONITORING OLOWSTEM DIA-OF BOREHOLE <br /> g EXTRACTION a AIR HAMMERIDRIVEN CASING THtCKNESS� TYPE OF CASING: g STEEL jff (]VC OTHER:, <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Cye- TI26ME TYPE TO BE USED AUGERS ICI HOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes ff<9jN0TF MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> II OTHER: d OTHER_ APPROX.BORING DEPTH '— 7ED TRAFFIC BOX or p STOVE PIPE <br /> 4 C NDUCT R CASING PROPOSED? (If YES,list spedfications here):_ <br /> *COMMIENTS: I � <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordl1iAAnances, Ill and Regulations, and all applicable California State Law . <br /> Signed x_ AX� — TitlelCompany <br /> Nnt Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR SS: / c L'�j — <br /> WORK PLAN DATED: Js <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date _ <br /> Destruction tnspectlon By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PI=CODES FEEINFO AMOUNT RI:IVIt7TED CHECK# REC-D BY I DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC--WAIVER­ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />