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09:'25/2000 14: 35 20946E3D6'�3' FIFTH FLOOR, PA`GE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> i-SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ,IAN 19 Z001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> � RP��T��ERVtCES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application i re5y made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance mth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ++LL Assessors <br /> WELL Location_17"I W, S e �� �� �c:(.Cross Street Ciry .a-C Zip 5 3 6 Parcel# 2o9- Z.`fD_Z:y <br /> PROPERTY OwnerOWP�f- &-c c LWT q _Address 0 ,.-).S kk,,(14- CityTcZ._c.,. Zip'15-31 Phone# 2 oq•--9-3k -R L 1 L <br /> 51 <br /> + 5-177-2-b'O <br /> C-57 Contractor�f�<'c-T f to w� (( /^Address 7-3 bS-1A),����w� �r City S-�.t L u�Zi�p Z°�/Lic# Phoned <br /> Consultant 1 Sub Contractor-C-5 o.1 CA r ASsa t, Address_ CN,=,va A,,,cCity 6Phone# ��8�� 3cj- /0 c <br /> GIS Coordinates.X 'Y Township Ranee Section <br /> WORK TO BE PERFORMED! <br /> a NEW WELL!BORING(CPT.GEOPROBE,HYOROPUNCH,HAND-AUGER.OTHER-) a DESTRUCTION(choose type below) <br /> U SOIL BORING;< 0 OVER-BORE <br /> 0 WELL# U PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> P40NITORING gT-iOLLOW STEM DIA:OF BOREHOLE G iA- MULTIPLE CASINGS?0 YES U NO 'NELL CASING DIA; L i <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS-0-11 - TYPE OF CASING: 0 STEEL 94VC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS UHOSErt,e" <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: &-Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'} <br /> 0 SOIL BORING U HAND AUGER GROUT SPECIFICATION <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH U BOLTED TRAFFIC BOX or DOVE PIPE <br /> CONDUCTOR CASING PROPOSED? tfD (if YES.list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ' CALL T E UNIT IV IN PE TOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED <br /> JINSPECTIONS <br /> Signed s n // Title/Company r(��e + a"cc ya fro �d+z r r-1S s a ctti�+� Z� <br /> Print Name Eetn ��- . lge_ j✓x vws Date /O I <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued 3 6 e <br /> Grout Inspectlon 8y Date Final Inspection By Dater <br /> Destruction Inspection By Date <br /> COMMENTS/rCONDITIONS: cG <br /> l "Z <br /> ACCOUNTING ONLY: AID# FACV <br /> II PE CODES FEE INFO AMOUNT REMITTED CHECK tt RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> A 169 IkkI z3 R# 0 - Q5 <br /> C-57_ WC/WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/12/00 <br />