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10-24-2000 03:40PN FROr TO 15306766005 P.02 <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 and/or install the work described. This application is made in compliance with San <br />Joaquin County Development <br />Title, Chapter 9-11y15.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location d.UJ _ 1 (�Vyz* t 5�w'1 5 fi t!� Assessors � 3 <br />Cross Street ' 1rf " City�l��� Zip�Parcel,. ! ? l) 3 <br />t Il_.1 <br />PR01 <br />C57 <br />Cons <br />'Ll,YZ Zip_r 455tiLic# Phone#(I i-j13-5)Mi.) <br />" <br />0"'C.44 eb"l-r I( Lic# Phone# e ,7E <br />GIS Coordinates: X , Y , Township Range_ Section <br />WORK TO 13E PERFOPMED <br />EW WELL/ BORING ( CPT, GEOPROBE, HYD ,PO,PUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />JSOIL BORING # ll'-' I -`� 411 . I I, L2 (- OVER -BORE <br />,RWELL # rYlli" - to PRESSURE GROUT <br />'Other; Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />MONITORING `$HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR p MUD ROTARY <br />p AIR SPARGE p PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE '" MULTIPLE CASINGS? 0 YES KNO WELL CASING DIA: <br />CASING THICKNESS & TYPE OF CASING: [1 STEEL R-OVC n OTHER: <br />DEPTH OF GROUT SEAL 1 tt TREMIE TYPE TO SE USED: 0 AUGERS a HOSE <br />GROUT SEAL PUMPED: ff�es p No {NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />0 OTHER: APTHER APPROX. BORING DEPTH IIS -) 46' _ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />+.90Y <br />t �D I jQ �CrONDUCTOR CASING PROPOSED_ L% (if YES, list specifications here); <br />`COMMENTS: 1.9I�14r�Pll ftoo19 i2' N;YNi � CI_," <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 Ordigances R le� and Regulations, and all applicable California State Laws. <br />Signed x ✓t vl� Title/Comp 5� l'x¢1('i <br />Print Name '�) c� �Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Date issued 2I (5 Area <br />Grout Inspection By ,Date Z <br />lc:/ Final Inspection By y- t; ,i L �_ �_ _ _Date <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: <br />AIDP <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />oO <br />Ove } <br />C-57_ WC= WAIVER,,,,,_, C-57 Letter of Authorization to sign permit_ Encroachment doc 9/27/00 <br />U`'tD.00 ZZ ii U5 TOTAL P.02 <br />