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. 1 <br /> PAYM E^,!-I WELL PERMIT APPOCATION FORM SITE <br /> '77f-,EIVED GATlON M�T1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIIV <br /> X2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 r <br /> N J(j-UUIN 60UN'IY 458-3449 <br /> r1tIBLIC!,r4LTH SERVICES (209) <br /> . <br /> 1-.%1!rlinlv" JAN 2 2 2002 <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 applicatiorJn^i,�,Wade in compliance with San <br /> Joaquin County Development Title,Chapter 41115.3 and the Standards of San Joaquin County Public Health Services,EnkrtiHmental"r-J t1.4.TH <br /> FRFMQnT S 5+, I'as, r,Vii ES <br /> WE?L Lt1ocation -11 4 O E A5 T FR c I/1 o()� S} Cross Street E•.e O AQ S+, City T�C KT^�p 9 S 21D� <br /> PROPERTY Owner 15&lbiA Gtr ddress yl a o Y RST FRP�+D ity C —LLoi1ZIp_ ELI)Phcne#Ad)1, 7�� 9 5 <br /> Or;1VAh '301 FitZ° rc.)D ST. AAvc.14 'TS74t s ci91b 638 7d7 b <br /> C-57 Contractor w EST 1-I AA Z1w4 G} Address S v i41= City�o r ow f Zp Lic#5 7 Phon r U <br /> Consultant/Sub Contractor 71.G.1_ . Address 7 SF{A,1 / 0/}D City5/OC CTon Lic#�7 Phonex�2 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION (choose type below) <br /> SOIL BORING# P-1C),F P7// r-12 0 OVER-BORE <br /> ELL# M W-4 a PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS SEE AAjenowyN To w orlc PjoN 6}TED 17 Jyj Zoo l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGHOLLOW STEM DIA.OF BOREHOLE rS--MULTIPLE CASINGS? BYES PC WELL CASING DIA: Z" <br /> EXTRACTION (I AIR HAMMER/DRIVEN CASING THICKNESS Ngo V1>; TYPE OF CASING: 0 STEEL XPVC ()OTHER: <br /> p VAPOR MUD ROTARY DEPTH OF GROUT SEAL 35 Ft>} /1)GTREMIE TYPE TO BE USED: AAUGERS 0 HOSE <br /> p AIR SPARGE Q PUSH POINT GRCUT SEAL PUMPED: )]Yes �lo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS: P 01'T I A wD k"1 Y A+' <br /> 0 OTHER: ❑OTHER APPROX BORING DEPTH_6Q' BOLTED TRAFFIC BOX or 0 STOVE FIFE <br /> CONDUCTOR CASING PRCPOSED? A/o (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 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. <br /> Signed x -T 1 Title/Company PRO P(,Ti G Fo/0561 S? A G• r <br /> Print Name //Mo ThJJ)Y CV Q 11A& Date 0� Z- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS?,. y�GO <br /> WORK PLAN DATED: <br /> --r--- <br /> Application Accepted By ' Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY jDX�E PERMIT/7777" 6- <br /> INVOICE <br /> zr z <br /> oachment doc_ 9/27/00 <br /> r <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign pertnit�Encr <br />