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12/05/2001 10:40 2094693433 FIFTH FLOOR PAGE 02 <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 appllcation 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 /> Assessor's 0 -01 <br /> WELL Location 3Z /$ IJ <br /> &,4v&,4y Drives crossStreetCity Sfbcltn�oZip $ZO Parcel# /b/-03 <br /> PROPERTY Owner r4o, > t'rSliW.Address 1.0.80X^'1369 City I'/ 0h--^ .ip�JOPhon,#. L% 2355" <br /> C-57 Contractor fTrtw Dry-1- AddraLss 9Jr0 L�enht_ �KC11 City QAC ip tqM�+ �.Li�c# �/+sPhone# <br /> Consultant/Sub Contractor Tox;c69A �wT _Address // / e nh n Ayb City S Mw..�r 9�70Phone#&ER-5S!—OI/Z <br /> GIs Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> R NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH.HANO-AUGER,OTHER-) IZDESTRUC71ON( oose type below) <br /> 0,901L BORING# VER-BORE <br /> ,P`CVELL#,_A2t/-� 0 PRESSURE GROUT <br /> 'Other: Grout Speclliications: <br /> CO;- <br /> W— overd trg3m.LA, +'evt <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I as 56 • M <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE�.�� '_'�MULTIPLE CASINGS? O WELL CASIFr— NG DIA: _ <br /> 7XTRACTION R AIR HAMMERIDRIVEN CASING THICKNESS, TYPE OF CASING: 0 STEEL 001�VC R OTHER: <br /> APOR R MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE U$ED: GAUGERS R HOSE <br /> R AIR SPARGE R PUSH POINT GROUT SEAL PUMPED: D Yes Oo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R SOIL BORING R HAND AUGER GROUT SPECIFICATIONS:�5nt $1 S76"V,;+L- <br /> R OTHER: R OTHER APPROX.BORING DEPTH 22' R BOLTED TRAFFIC BOX or VfTOVE PIPE <br /> on I' ci I l CONDUCTCfR CASING PROPOSED?_& (if YES.list specifications here): <br /> 'COMMENTS: �LtX� Ez <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 fly-It _LX4r tee , Dr:1� Title/Company Se4yr- [' C-ol•h%sl��x����^^ + <br /> _Date <br /> Print Name —�� T..I/- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> p Datelssued / C o1- Area C[/R.r✓62 uT <br /> Application Accepted By !�M-P`-'\ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a-9.Oz 60' (-d' loi 3 !•G& / / oz- 00 ss <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc, 9/27/00 <br />