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01/19/2001 16:05 20946E3433 <br />FIFTH FLOOR <br />PAGE 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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />pplication 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 />3aquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaouin County Public Health Services. Environmental Health Division. <br />Assessor's <br />JELL Location y--21.--ovni-6,z_: Cross Street /APIA& 41/City r r Ai Zip (-1S2; Parcel# <br />'ROPER-FY Owner e,--0-gge.-- 7u.14t Address IM7 eihrta4- AAP( City Phone# <br />:-57 Contractor AZ,---5r 41-241•07- Address ?2;3 Fe rz‘tetecelo cityi,VV4-- zip rs-Ne Lic# 53'lf Phone#14638 - <br />:onsultant /Sub Contmcipr ...r-r•trehrifaikrniks 3°1.7 -%g ‘11City (4+16(--e-44121'f- Lic# Phone# (76)2er/- °Yck, <br />3IS Coordinates: X . Township Range 76T Section /46) <br />SITE <br />MITIGATION <br />UNIT IV <br />VORK TO BE PERFORMED: <br />XNEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER") a DESTRUCTION (choose type below) <br />U SOIL BORING # a OVER-BORE <br />N\WELL # mai-6 a PRESSURE GROUT <br />Other: Grout Specifications: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g if MULTIPLE CASINGS? [.1 YES ii(NO WELL CASING DIA: 7 <br />CASING THICKNESS .51:re" CO TYPE OF CASING: a STEEL AVC (1 OTHER: <br />DEPTH OF GROUT SEAL 447 TREMIE TYPE TO BE USED: !It&LIGERS a HOSE <br />GROUT SEAL PUMPED: a Yeso (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: ‘eff <br />APPROX. BORING DEPTH 63— Af'BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED' 449 (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, R s and Regulations, and all applicable California State Laws. <br />Tide/company -.5t02-.11- Agrall <br />TYPE OF WELL INSTALLATION TYPE <br />/MONITORING frkiOLLOW STEM <br />a EXTRACTION a AIR HAMMER/DRIVEN <br />a VAPOR UMUD ROTARY <br />a AIR SPARGE fl PUSH POINT <br />a SOIL BORING Ei HAND AUGER <br />a OTHER' a OTHER <br />Signed x <br /> <br />S <br /> <br />Date <br /> <br />Print Name_ DEPARTMENT USE ONLY <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By Lk .--tivv.... c---- Date Issued -3-- /tylc7/ Area <br />Grout Inspection By LciA346---. Date Final inspection By ( L---L-1,1--t, e--L-Lek Date <br />Date <br />ACCOUNTING ONLY: 4AJD# <br />Destruction Inspection By <br />COMMENTS I CONDITIONS: <br />FAC4 <br />INVOICE DATE REVD BY CHECK If AMOUNT REMITTED FEE INFO <br />Ritt,OM0G <br />PE CODES <br />1- 19 0/ <br />PERMIT / SERVICE REQUEST 4 <br />9)27/00 <br />-WAIVER <br />, 00 <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />C-57 WC