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10/25/2001 09 33 2094683433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FORMA S <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT N <br /> 304 E. Weber, Third Floor, Stockton, CA., 93202 <br /> (209) 468.34490- lztrc <br /> NON-REFUNDABLE PERMIJ EXPIRES 1 YEAR FROM DATE ISSUED <br /> AppGr bort'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 Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services Environmental Health Division <br /> WELL Location� n�S �p� &ni6i Re RA Cross Street C1ty Q 1VC r6LA F,ZapAsesses Par } oZ4 4-C-7O-Cr <br /> PROPERTY Ownery fD i�Q� Address2�6�5 ovt•� _CA#g�amity ,,l���YRA IC Zp q 7 Phone# 9 V6-?6 <br /> C-57 Contractor G r,II i n Address 'ISO ROWS P-d C,ty Pier- ; ZIp9t1S'S3 Lia LL I6 -Phone# tf3`13 <br /> Consultant ISub ContractorsLCOR _1_ `tern+}Hun,4 Address 13w Ki 6,e d S ILtC)CetyRgnCiw Lo ic'�#� 6It]Z Phone# 9� $b1`d10D <br /> GIS Coordinates X Y ,Township_ 3 Range ri SL Section <br /> WORK TO BE PERFORMED <br /> XNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH HAND-AUGER OTHER&) 1]DESTRUCTION(Choose type below) <br /> :SOIL BORING# CPT— 11 OVER-BORE <br /> {]WELL# [I PRESSURE GROIN <br /> Other Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I]MONITORING U HOLLOW STEM DIA OF BOREHOLE Z" MULTIPLE CASINGS?Q YES 0 NO WELL CASING DIA. <br /> ii EXTRACTION [i AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING <br /> JI STEEL p PVC []OTHER <br /> OR [t MUD ROTARY DEPTH OF GROUT SEAL 6S" TREMIE TYPE TO BE USED II AUGERS p HOSE <br /> [FWSPARGE PUSH POINT GROUT SEAL PUMPED i]Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> };SOIL SORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER [I OTHER APPROX BORING DEPTH 4L9' []BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (,f YES fist 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,R les anti Regulations, and all applicable California State Laws <br /> s,snedx_Yd Tltle/Company nro� �eo1 ;fit SfiLoR Z04recnutio++41 `b <br /> Print Name Jmr A ill�.'1�� i e Date I O� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2356 s• r�r f� �� <br /> WORK PLAN DATED' Y4 AtlWO ! <br /> Appirrat,onAcxepted By Date Issued ^ Area CJYl <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection BY Date <br /> COMMENTS ICON DMONS_ Cx fiGe�� iQY►- r-- <br /> qp"IjTiNG ONLY AJU# <br /> PE COI�1lS FEE INFO AMOUNT REMITTED CHECK 1!t REC'D BY DATE PERMIT I SERVICE REQUEST 9 INVOICE <br /> C-57 .__WAVER C-57 Letter of Authorization to sign er•mit Encroachment doc 9/27/00 <br />