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11/09/2001 15:08 2094683433 F7_FTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FOkM SITE <br /> - CD MITIGATION <br /> CQ 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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in ccmpfrance 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 /> Assessors <br /> WELLLocationAW72 VL /e ! A�2 Cross Street/7/� <rf wyCity ./1'l4ah'1cct ZiP 9c533 Parcetn p p <br /> r IC �j(/ j �C�7 Z S�, ypSlmt Cit c fC Zip/�� ? Phoned 2d/-23 -_ K <br /> PROPERTY Owner_ yn rn Address *%el7u e y r t�_ U ? <br /> C-57Contrador /� ri .tAddreess 5 I/Z !"/d�c� City R�v i"o,", Zip`/��Y1 Lic#ss�'y�` Phonek9/�-b�0 -7Z7�j <br /> Consultant/SubCont2ctor�y6r�, LICe Cj!^��Address 4. City n LicWd00 Phone# S <br /> i <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> ❑NEW WELL!BORING(CPT,GEOPROBE,HYDR _ _N,'HAND-A�JGER. ER') ❑ [)OVER-PORE <br /> fl <br /> WELL T A./ 1�!_1 ❑PRESSURE GROUT <br /> *Other: �" �--i—Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?.G YES *NO WELL CASING OV, Z <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS '4 q6 TYPE OF CASING: I)STEEL PVC 0 OTHER: <br /> VAPOR []MUD ROTARY DEPTH OF GROUT SEALS �� TREMIE TYPE TO BE USED AUGERS Q HOSE <br /> AIR SPARGE PUSH POINT. GROUT SEAL PUMPED: ayes�1No.(NO/TE: MAXIMUM FREE ALL DEPTH IS 30') <br /> 1]SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS: t 1 aAL";r <br /> ❑OTHER: ❑OTHER APPROX.BORING DEPTH �'fl LQ BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CON DUCTdR CASING PROPOSED?4_/Z_(If YES,list 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 /> I hereby certify that I have prepared this applic Ion and that the work will be done In accordance with San Joaquin <br /> County Ord' nc s,pules and Regul s, and all applicable California State Laws. (�' <br /> (f l (J k'6/dNA'L- k_tW 1_&_L_ /V1.�1 ��H-ZI�1/���[tl�(. <br /> Signed x TiVelCompany - <br /> Print udrF'�'^O �Jtl+fir�— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: d,D 3- d `le5 eL,-L k fir+^^ ' fes^ C <br /> WORK PLAN DATED: l5 Tt 3 It C> <br /> _— <br /> Application Accepted By Date Issued 1 Z / Area <br /> Grout Inspection By Date 11 a Final Inspection By <br /> Destntcdon Inspecfion By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REIIIITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a. z 3 <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />