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01 / 19/ 2001 16 : 05 20946834 .3 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS=EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA. , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> pplicatIon is hereby made to San Joaquin County for a permit to construct andfor install the work described- This application is made In compliance with San <br /> 3aquin County Development Tifle, Chapter 9.1 115.3 and the Standards of San Joaouin County Public Health Services. Environmental Health Division. <br /> _ �7 p ._ • I I S PAastcseels#s <br /> ors <br /> TELL Location Ov�_ �/ CtvssStreet7City5 ZiP q5Z <br /> ROPERTY Owner /O�/ dA&76AI AddressllbbI / ke` <br /> City ✓rk Zip _Phone# 9/` <br /> -57 ConvactorC- ��IJE A¢/ Address• 'LO',0I Gi.� City�ZipIIIIIII_`/z Liax JI7S�0 Phone# 96 <br /> `� � 0 <br /> :onsultant I Sub Contractor...l�o/L lic/T�/Qjjiff)� dress 3617 AgX*JC 210 City Lic# Phone# 9/6 B6/- D 00 <br /> ;IS Coordinates: X., Y , Township Range Section <br /> YORK TO BE PERFORMED: <br /> I NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCHy-HAND-AUGER. OTHER•) [] DESTRUCTION (choose type below) <br /> SOIL BORING # _ S O / 0 OVER-BORE <br /> WELL # — .S 0PRESSURE GROUT <br /> Other. Grout Specifications: <br /> ;OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM DIA, OF BOREHOLE �Z/ MULTIPLE CASINGS? n YES ,ANO WELL CASING DIA: Z <br /> ] EXTRACTION 1] AIR HAMMERIDRIVEN CASING THICKNESS SL/f TYPE OF CASING: U STEEL $PVC U OTHER- <br /> ] VAPOR o MUD ROTARY DEPTH OF GROUT SEAL �S r TREMIE TYPE TO BE USED: GAUGERS Q HOSE <br /> ] AIR SPARGE 1] PUSH POINT GROUT SEAL PUMPED: li Yes 0 No OTE: MAXIM M FREE-FALL DEPTH IS 30') <br /> ;] SOIL BORING O HANDAUGER GROUT SPECIFICATIONS- L^ `^'t Ce <br /> OTHER!.0 OTHER APPROX. BORING DEPTH7, BOLTED TRAFFIC BOX or [] STOVE PIPE �^ <br /> U CONDUCTOR CASING PROPOSED' OWV ( If YES, list specifications herel: \� <br /> -COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS . C <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 ules and Regulations, and all applicable California State Laws. Cr <br /> Signedl Title/Company_ ���T ���/` / G�'� <br /> Print Name Date <br /> P <br /> �G � DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: — <br /> Application Accepted By wzvL ° Date issued I �� (DI Ares-410 1P 3 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> WIN <br /> COMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT 1 SERVICE REOUESi S INVOICE <br /> 7S01 <br /> mit_ Encroachment doc_ 9/ 27/00 <br /> C-57_ WC -WAIVER_ G57 Letter of Authorization to sign per <br />