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10-24-2000 03:40PM 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 Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmentaf Health Division, <br />4 J �` Assessor's <br />II,IIJJ ' Sfiw� r Cross Street' �i 5t, ty�r tl i'n� Zipi 5,� �I Parcel# f5.z ., <br />WELL Location 7 "l.l;_ F v'�'t1Cv+, I, 1, Ci <br />PROPERTY Owner + (+ 'C�` Df' <br />rt'1� Address. 4 515 h� YIFJ 5 i,av� City r 7'✓1 Zip f`] �I L Phone! <br />l � l <br />C57Contractor /iq Ili+I� •j1+��T Address / City �4 I 1 Zip�)i1 ��S Li I'� PhonenC; J '13 .�SOb <br />Consultant / Sub Contractor 5�<Gl � �✓t�1 rQI�YI�vU� r� Addres5�� ''IJI►1�r�11TrUi(. j��+ t$�7 City�4Nly �c✓ Lic# Phone# 5 �- 1 kTq <br />GIS Coordinates: X _,Y Township Range_ <br />Section <br />WORK TO DE ERFO MED - <br />NEW WELL /BORING (GPT, GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />SOIL BORING # Q I – 2 0 OVER -BORE <br />0 WELL # PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING Q HOLLOW STEM DIA. OF BOREHOLE '? MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC 0 OTHER: <br />Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: (I AUGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: $ Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D401L BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br />a OTHER: 'E[OTHERL, I APPROX. BORING DEPTH 115 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED4 (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 <br />/Laws. J <br />Signed x._ �?�?�_Ll_yull� 7iile/Companyt (;{�d�d�,,Jf /q�L`S �c�vi�Jrll�ti2' r'�+c, <br />Print Name—S uc 1L. t Date IU' �' /rte. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By e_- Date Issued ---1 ZI Area <br />Grout Inspection BDate -3-4)z 1 C' I Final inspection By .. � , I t, L1 � C Date Z z <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 <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3S'OI <br />(,00 <br />0606 <br />Z �C/ <br />Q0d�� )� <br />C-57_ WC --WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />,,'o' Z Z I LP 5 TOTAL P.02 <br />