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11-OG-2001 01:32PM FROM TO 19259432366 P.02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> N;'J':/ U CQ�1i SAN:JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> - -t 2 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> 'application is hereby made to Ban Joaquin County for a permit to Construct and/or Install the work described- This application is made in compliance with San <br /> ioaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> HELL Location V{ ✓�,A II CfS,3aS Parcel# ZsS'-/80 08 -5 <br /> 3sioa s. h 33 Cross Street�12� �.2Clry l 5 Zip <br /> ?ROPERTI!Ownerry s 0c D4dress 3S/rib S f>L��N J3 Clry <✓✓t�t�r3 Zip SY 385Phone#�2o� �g3S-7Sq <br /> 'Pr b Address� D l ox 0�l 3 CityDrov) l<< Zip9 <br /> -57 Contractor Np <br /> 5966Li�ts �s,one � o S8 q-2oJ� <br /> Consultant/Sub.Contractor�> .Address IS>70 A) 'I( /�VC'C+tY a!`nJ� �►C ictf N/� _Phone# �gLs�9143' 303 <br /> C>0 <br /> W3 <br /> GIS Coordinates:X Y Township .S Range C Section <br /> WORILIO'BEERFORMEDi <br /> EW WELL/BORING(CPT, �,HYpROPUNCH,HAND•AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> OIL BORING# Z 3 [1 OVER-BORE <br /> HELLO PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: I' <br /> �s•2�- �©r k- -P <br /> TYPE OF WELL INSTALLATI N TYPE! CONSTRUCTION SPECIFICATIONS r, <br /> Q'MONiTC�RING []riOLLOW STEM DIA OF BOREHOLE 2� MULTIPLE CASINGS?a YES (j NO WELL CASING,DIA: Z O D <br /> Q EXTRACTION QAIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL �C Q OTHER <br /> lJ VAPOR QiMUD ROTARY . DEPTH OF GROUT SEAL O-)0r�TREMIE TYPE TO BE USED: Q AUGERS �10SE <br /> lJ AIR SPARGE H PUSH POINT } GROUT SEAL.PUMPED: Q Yes Q No (NOTA: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING [];HAND AUGER GROUT SPECIFICATIONS: L 2 —Q r 0 <br /> UbsQ-voc} O <br /> HER; LUTHER G�toprobG APPROX.BORING DEPTH 3 L _ BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N b (if YES,list specifica�ons here): <br /> `COMMQ4TS: ✓L I(o —P o '� Or>`2 vk9� / �t/ A <br /> Cc, 2'3 t4-2 L -� c r f o I S , l o r <br /> NOTE: ;OFF E BORINGS REQUIRE ACCESS O ENCROACHMENT ER IT . <br /> 'CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that Ihave prepared this application and that the work will be done in accordance with San Joaquin <br /> Count} Ordinances, R es and gulations,and all applicable California State Laws.La�ws. <br /> Signed x. Title/Company J�-�rR� O Q f S� -- ' <br /> Print Name A Date I gj O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORD PLAN DATED' <br /> Application Accepted By Date Issued �l S/G i Area< Yh ✓�� c., <br /> .Grout Inspection By �^a e� Date �7J �Z Final Inspection By <br /> Destruction inspection By Date <br /> n 1 p � <br /> COMMIJNTS/CONDITIONS: /> t� - <br /> i <br /> ACCOUNTING ONLY: AI DR <br /> PE CgDES FEE INFO AMOUNT REWTTED CHECK# REC'D BY DATE PERMIT i SERVICE REQUEST# INVOICE <br /> C-571— WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 9/27/00 <br /> TOTAL P.02 <br />