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0P/19/2001 16:05 20946634?: 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 /> pplication is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made In compliance with San <br /> Paquin County Development Title,Chapter 9.1115.3 and the Standards of San Joacuin County Public Health Services.Environmental Health Division. <br /> �[ --,, Assessors <br /> TELL Location 7� C1t0/lyl)'9+Gf,_ _Cross Street49/ciry 57b(t rOry Zip�15Z Parcel# <br /> •ROPERTY Owner� _' S Address?kezW*f-/`2 AAW c�ityy�5�: xnwn zip �"6 PhoneC Zo`t tY 6St <br /> :S7 Contractor Wv /p¢z�t(.}f Address �23� .(li RO Ciryr — y}—Zip /L Lic#X579 Phone6 w Gip - 7L7kj <br /> .,L�s_;017 � fU City Lic# Phone# <br /> :onsultant l SuSCenkar3Pr I� <br /> )IS Coordinates:X .Y .Townshlp 71-.1cl Ranged--776- Section Aa <br /> NORK TO BE PERFORMED: qpe <br /> KNEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER') O DESTRUCTIONO(OVE(choose <br /> low) <br /> 0 SOIL BORING# <br /> 0 <br /> 3KWELL# "OV-6 PRESSURE GROUT <br /> Grout Specifications: <br /> Other. "� <br /> :;OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> PONITORING OLLOW STEM DIA.OF BOREHOLE r MULTIPLE CASINGS?DYES )(NO WELL CASING DIA:? <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS fU*- qP TYPE OF CASING: 13 STEEL XVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4 _TREMIE TYPE TO BE USED: UGERS HOSE <br /> 0 UMPEO: 0 Yes Ao (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE O PUSH POINT GROUT SEAL P <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �/G_91 C�/r1E�/t <br /> 13 OTHER!_0 OTHER APPRO)C BORING DEPTH BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? es (If YES,list specificatlons 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;able Californiaork 1l be done in S ate Laws. accordance with San Joaq <br /> County Ordinances, R s and Regulations.and all app d� <br /> ,r ,C -Sllz <br /> Tlde/Company �0 <br /> Signed x C_ a v <br /> 1/T Date_}� <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> t Date Issued <br /> Application Accepted By ti��-n Date <br /> Grout lnsPeWon By <br /> D2. G^ate Final lnspacdon By <br /> pesbuction Inspection By <br /> Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMDTED CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST INVOICE <br /> iso e-y , on tj 7,_ b & � C, (CC) <br /> C_57_. WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment 00C_ 9/Z7/00 <br />