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+� FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> -� %�-- MITIGATION <br /> NOV 0 5 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRO ; - • 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERP'iT tFI l % (209) 468-3449 ORIGINAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 /> r _ Assessor's <br /> WELL Location 7J- W ��l-PI c0 jZOA9 Cross Street S•1 RACY ?LVD City I rtAeY Zip 015376 Parcel# 246-t30-04 <br /> PROPERTY Owner CtrY of: 1rLACY Address 920 S--TnLACY $LVD. City"•� rLAC/JYr,�,�� Zip 95376 (zo <br /> Phone# 9� 931-4420 <br /> C57 Contractor "^7 <br /> -^ gAddress/7U)lam, 5e _Citybei^" Zid/Yd�:-Lic#6A9Nbhon ]O �7'95?j <br /> Consultant/Sub ContractorAOTotJ µ1CI4eLS0A/ Address SOSO 1L1hArHCWS EL D o nP90 City HrLns Lic#nrSSoB Phone#(91(1)Q3Q-7SS0 <br /> GIS Coordinates:XL�i: 3�.-linY7rS,YLo.1G: -tzl.'1258YyS,Township O2 � Range 051F Section 33 <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') []DESTRUCTION(choose type below) <br /> :5SOILBORING# IC1 -7br4L - Se6 C�MMF�JT5 [IOVER-BORE <br /> fl WELL# �NO A/6-) []PRESSURE GROUT <br /> 'Other. Grout Specifications: di:AT CATH t°� <br /> COMMENTS: S61 Tv 9611 PB-SR-I -2 3 SC2-HPI 6c3-HPI PB-CPT- 1 -2 -3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLEI 75„ MULTIPLE CASINGS?[]YES [INO <br /> WELL CASING DIA: ^�A <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS VA TYPE OF CASING: []STEEL []PVC []OTHER:NoAJE <br /> []VAPOR [j MUD ROTARY DEPTH OF GROUT SEAL•Co-rA t- o£P-IN TREMIE TYPE TO BE USED: []AUGERS XHOSE <br /> []AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Ayes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [j HAND AUGER GROUT SPECIFICATIONS: .VkFAT C gAgc v- <br /> []OTHER: []OTHER_ �APPROX.BORING DEPTH SES Ca- CUTS aBOLTED TRAFFIC BOX or []STOVE PIPE <br /> .`IY. CONDUCTOR CASING PROPOSED? No (if YES,list specifications here). <br /> 'COMMENTS: SOIL CAS S 4} Y So � gD21�bS • 25 ;4- d wrorLoi;­c.I : 10 Si cpT : (00 At <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 and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company /�ROJdC i E✓G' ./�aR�iBC>a^i H(CKEr-6 0</ <br /> e l/`-�a�R> L. �/.>MMON� Date //-Z- <br /> Print Nam0y <br /> j (DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 0`� 1 0 //�► <br /> Application Accepted By <br /> Date Issued rO Area V <br /> jl <br /> Grout Inspection By Date Final Inspection Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS:_ <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 29D S 5.A <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />