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0 >. FILE '[PY <br /> [ C��ii` D WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> AUG 1 6 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIROPJVENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT,/SERVICES (209) 468-3449 fl � <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location -2-33 to3f-fi6t S SqrrIa P Ra,Cross Street city Q:Yet-6a&k .Vi Zip Parcel# 7-49-070-otl <br /> PROPERTY Owner-Ivran TG LO1 6 Address 7-2.31 City 10 Zip eg�S'_ QPhon gag-[Sb3 <br /> C-57 Contractor(S C7riI1jA5 Address R� Flowe R& City NAr(-tiflQj�ip qy F3Lic# IgSI6S Phone#[g L-`Sai3-.S$CV <br /> Consultant I Sub Contractor SBCciQ '$-A{erKl %Ongl Address3017 lCrl5o'e R ,SW-'1 ityaQnc1.o Za-,.ILIc# 610 7- Phone#t9 I4i 961-04400 <br /> --vo'v; <br /> GIs Coordinates:X .Y ,Township Sou+ Range 9 est Section 7-4 _ <br /> WORK TO 8E PERFORMED: <br /> ` NEW WELL/BORING(CPT,GEOPROBE,H ROPUNCH, D-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING GPT- 11 OVER-BORE <br /> Q W ELL# a PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE /�MULTIPLE CASINGS?Q YES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC o OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL bJ TREMIE TYPE TO BE USED: D AUGERS HOSE <br /> U AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: p OTHER APPROX.BORING DEPTH h S� 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rulesarld Regulations, and all applicable California State Laws. <br /> Signedx /�/r� pp Title/Company SFCoR �n�42rtnw'FiO�n0. Znc, <br /> Print Name 4t'T Date g 3 01 <br /> DEPARTMENT USE ONLY l <br /> SITE MAP IN UNIT IV FILE, ADDRESS: / AqrL'� <br /> WORK PLAN DATED: ©� <br /> Application Accepted By Date Issued <br /> Area <br /> Grout Inspection By Date Fnal Inspection B Date ()2 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDRIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REM: ED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 5 10050101g5 -� 7-7-(0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br /> A"y,p ,QC <br /> CO 39Vd 2100"ld H13Id E£4£89460L iE £I 0002/b0/LT <br />