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Sep-24-02 02 : 34P VIRr `IEX, INC . S- S68 7679 P - OS <br /> VO I D WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> 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,Cha ter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Zip 266 arcel# <br /> Assessor's <br /> 1(o3 — 31U—pa <br /> WELL Location CrossStreetr CY�.o City S4zc4-k 5 <br /> PROPERTY Owner < Address oL City Zip 5206 Phone# 20`-_ <br /> Scv'1 _ <br /> C-57 Contractor VI(LO 11C: K Address ,E CityZip9L'�; Lic#7,11.:'J Phone# 5/0 SL.V- <br /> Consultant/Sub Contractor� Address May 1,0A WOr„City Rte k -4ic# Phone# CSIo�23� -32_00 <br /> so,j+t, _, x 14 I <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a, W WELL ORING PT, EOPROB .HYDROPUNCH,HAND-AUGER,OTHER') ESTRUCTION(choose type below) <br /> p RING# 'E,3-4 1] ELVER-BORE <br /> Ij WELL# RESSURE GROUT <br /> 'Other: 2' 56-I 4 '06r,l GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 3 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?DYES $NO WELL CASING DIA: <br /> 3 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS —' TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> ;)VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL At 20 1 TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> ]AIR SPARGE i15-U-SH POINT GROUT SEAL PUMPED: 0 Yes N No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> KSOIL BORING 0 HAND AUGER GROUT SPECIFICATION C <br /> ;j OTHER:_n OTHER APPROX.80RING DEPTH kaZ 20 r O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N U (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN A'DV'ANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x�. ti�_L��f3— ��? TiUe/Company UL.fZGYts�J� <br /> Tint Name Q _\5*�G� ���1 i Date 1 a y J b a <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> application Accepted ByDale Issued o-7 Area f D! <br /> 3roul Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS/CONDITIONS: w L� <br /> a 09 <br /> ACCOUNTING ONLY: AID# Lv yam"# INVOICE <br /> A,1-0PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'DBY DATE PERMIT/SERVIC / ��` <br /> '11-0r BS — 8y— fL1 Fuc <br /> C-57 WC/WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ 7/17/00 <br />