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10-24-2000 03:40PM FROM <br />TO 15306?66005 P.02 <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD 1;'I�` U'NITiV <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app Y on is made in compliancy with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public H/eslth Services Wonrnental oe,EIJh Division. <br />WELL LocationUS�i_.�hS �' �,r� 5 �, Cross Streetf�)�v'�L City 6k 4)1 Zip Parcel# o/j �- I )D -D <br />PROPERTY Owner�-toLni Fl�j�l v�Ji✓t>i�� Address_ 1�)s/✓K;�k'✓) 1�, CityS{CicK{ivl Zip%, ''Phone#'31-7�i7U <br />C57 Contractor I/il o;Lt1��v�Address 5 ' Rii&i 0, Lic# Phone, -,7,1%"3N 7,17144 320 <br />Consultant / Sub <br />GIS Coordinates: <br />Y , Township <br />�1�LS Z Phone# <br />Range MM M - Section <br />WORK TO BE-PERFORMED;- <br />0 <br />E-PERPO MED:0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE <br />0 WELL #/ RESSURE GROUT <br />-Other: Grout Specifications: (''fid U, r� <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />VMONITORING DHOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />D PUSH POINT <br />U SOIL BORING <br />0 HAND AUGER <br />D OTHER'_a <br />OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? DYES ONO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC [i OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes 0 No .(NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH <br />a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />`COMMENTS- 41''f5V`� � � I u ML'I.i <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 Ordinancees,,Rrules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company ),(-,.7- 1 ��Y " �h✓, •�i�C <br />Print Name S c�'1 �i%.�:Irir Date h - b -p i <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS:_ <br />WORK PLAN DATED: <br />Application Accepted By Date Issued CI Area <br />Grout Inspection BDate Final Inspection By Date c Y <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID;; <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />3 Z <br />,vc <br />����{ <br />j,•Q <br />`f b S <br />C-57_ WC= WAIVER, C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />TOTAL P.02 <br />