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10/25/2001 09 33 2094683133 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 C)rrl& ( pig <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application Ls hereby made to San Joaquin County for a permit to construct and/or Install the work descnbed TMs application is made in compliance with San <br /> Joaquin Caunty Development Title Chapter 9-11153 and the Standards of San Joaquin County Public Health Services,Enwrorimental Health Division <br /> WELL Location ISS-0S, S4lL'ha P-,Pt Kn�d qE 26 Assessor's <br /> Cross street CItY Q\Viii qR�- Zip � parcel]:2.t{9'070- Z. <br /> PROPERTYOwner U%av% JC,(i cyu+A 60. -A♦y Address Isi;- F 1I;02I K t A� City �r ac.i� Zip,gS2Z,S _4'hone#j? 46g"3a� <br /> C-57 Cantractar C,L7=P� �fii�4 i Address 0 g5l ovJe CitylIgr•4, Zip54553 Lrc# 8sI6 Phone#[g_ 2Sj3 9�S&'�� <br /> Consultant/Sub Contractor SaC_0P_ Z^`Ve-rrAi-'cr%01Idress 3012 11% Sip- fib City.Parc4 Grdic# 02- Phone# �oo <br /> GIS Coordinates X Y ,TownshipRange 4S t' Section �� <br /> WORK TO BE PERFORMED_ <br /> )MEW WELL/BORING(CPT GEOPROBE, HYDROPUNCH HAND-AUGER,OTHER-) 1]DESTRUCTION(choose type below) <br /> PrSOIL BORING# CP"1`— 3 p OVER-BORE <br /> [I WELL# U PRESSURE GROUT <br /> `Other Grout Specifications_ <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (]MONITORING [I HOLLOW STEM DIA OF BOREHOLE 11 MULTIPLE CASINGS [I YES U NO WELL CASING DIA. <br /> []EXTRACTION 11 AIR HAMMER1DRiVEN CASING THICKNESS TYPE OF CASING []STEEL [[PVC 0 OTHER <br /> [OR p MUD ROTARY DEPTH OF GROUT SEAL 65-' TREMIE TYPE TO BE USED "AUGERS HOSE <br /> SPARGE ;EPPUSH POINT GROUTSEAL PUMPED #Yes 1]No NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS _ <br /> p OTHER [I OTHER APPROX BORING DEPTH $�� [I BOLTED TRAFFIC BOX or q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES list speaficabons here) <br /> -COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules a d Regulations, and all applicable California State Laws. <br /> Sgnedx SW TBteCompany. SG-4SnP_ ZftCNgVto^a enc. <br /> Print Name iLT'T �VGI�*£t IOAI� Date <br /> DEPARTMENT <br /> USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued l`� Area <br /> Grout Inspection By pate Final Inspection By Date <br /> Destrucbort Inspection By Date <br /> comm ENT$l CONarnomS <br /> MPECODESrF�EERNFO <br /> ONLY AID# <br /> AMOUNT REMI'ti[ED CHECKS BY DATJF PERMIT!SERVICE REQUEST# INVOICE <br /> by 7b0 4102,7&0 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to s n permt_RL Encroachment doc-) 9/27100 <br />