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Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Lc) F----s-rfzcv" <br />. 02/13/2001 08:36 <br /> <br />2094683433 FIFTH FLOOR <br />PAGE 02 <br />• <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PIIS-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 />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 rifle, Chapter 9-1115,3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />C-57 Contractor 4-.1--A•Address 615c; t-tct..)e (-(A. Ci 9LiC#1 Phone# 53 43 -57? <br />Consultant / Sub Contracttpr i 0 _ Address i 11,71 city0r)1(IctvIckuct Phone# 16 2AA <br />2.101 GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL! BORING (97, GEOPROSE, HYDROPUNCH, HAND-AUGER, OTHER*) I] DESTRUCTION (choose type below) [I SOIL BORING to a OVER-BORE <br />a WELL # El PRESSURE GROUT <br />*Other. Grout Specifications; <br />COMMENTS: <br />SITE <br />MITIGATION <br />UNIT IV <br />6 tn. Acr,'"e-coNtris, en6 Assessor WELL Location Cross Sweet t:4-Q/0- 1‘.- 'City sk-pc( 1ry \ zip Parcel# <br />,Aatt \Teel- <br />-/,'IelAddress C- H:L y B Cit isIA-Pc_-ki-r if' Zip PROPERTY Owner 11-1X\ Phone# (_1(1 f <br />TYPE OF WELL <br />El MONITORING <br />EXTRACTION <br />VAPOR <br />O AIR SPARGE <br />)(SOIL BORING <br />U OTHER: <br />INSTALLATION TYPE <br />[I HOLLOW STEM <br />O AIR HAMMER/DRIVEN <br />MUD ROTARY <br />O PUSH POINT <br />HAND AUGER <br />OTHER I <br />CONSTRUcTioN SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? a YES a NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: fl STEEL U PVC U OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I] AUGERS U HOSE <br />GROUT SEAL PUMPED; kes No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED') ( 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 01:$*dinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: I Ls/ \ <br />WORK PLAN DATED: i .1 <br />)C/C--K2_ ritieic,ompanY <br />1/(41 6-Q-A Date) 7/q// <br />DEPARTMENT USE ONLY <br />Date Issued Area <br />Date B— 691 Final Inspection By Date <br />Date <br />COMMENTS 1 CONorrioNs. <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D StY DATE PE CE REQUEST ft INVOICE . <br />(Lc) c, ivy), y; ,, - ,,,, rix-) m <br />, m , <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign perm Encroachment doc 9/27/00 <br />