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10-24-2000 03:40PM FROM <br />TO 15306766005 P.02 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA,, 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 X1115.3 and the Standards <br />fof� San Joaquin County Public <br />{ Health Services, Environmental Health Division. <br />Assessor's <br />arcei# t —I )' " <br />PROPERTY Owner �iv .1�, K �h�wT��' ! Address V .t-, 11101 Uo, City. > k ZipI -1 Z Phoned - <br />C57 Contractor -Irp' i o, ,A 1 1��� Address �r �'d�ty ��� City. l tlafl, f1 C T- Zji)511 � f> Lic# 4 C A � Phone# 172 -13 _C L�0 <br />r j" I 1 Sa 1lull r.ti '* Lic# Phone# Sj(�"� %�1 br `' <br />Consultant/Sub Contractorutl�S��1u��(Y�i�i'rivtC�T�Addre553" �iJ(ayt1.?r �11.1i(I� City( rµ '7 r� <br />GIS Coordinates: X , Y Township Range_ Section <br />WORK TO SE_PERFORMED; <br />`XNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 0 DESTRUCTION (choose type below) <br />SOIL BORING # LCT I 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />"Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING a HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />a PUSH POINT <br />SOIL BORING <br />0 HAND AUGER <br />[J OTHER: <br />`OTHER 1�" 1 <br />_ c' 1 <br />"COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE !' MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />GROUT SEAL PUMPED: `,Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH II `' O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here):_ <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 />1 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. I <br />Signedx '�it...W�f Title/Company S WL.�'? L,<,tT �S�/OhS)'NViiojim-'tifw''� ;. <br />Print Name �t��li J,�����,.��� Date �Q 1-5 <br />r%1 M A 1'9T■■C11T 1 I^L /%\11 V <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By LWAA ACCjL,-Date Issued -Z-1 d� Area_ <br />Grout Inspection By. Date ---:'d Z Final Inspection By 1 5,u, c Date <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 It <br />INVOICE <br />350 <br />_do <br />(macCTcy <br />� <br />C-57_ WC= WAIVER _ C-57 Letter of Authorization to sign permit—e=ncroachment doc 9/27/00 <br />��OOZ LI �Py_ TOTAL P.32 <br />