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GIS Coordinates: X , <br />County Ord' nc s, ules and Regul <br />Signed x <br />Pnnt N <br />11/09/2001 15:08 2094683433 FIFTH FLOOR PAGE 02 <br />CD <br />(7‘..2 <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 />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct andlor 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, Environmental Health Division. <br />Assessor's <br />WELL Location& 72. 4." /1.k/ini le --pets< Cross Street 47011-- W y City ../1,41/ack Zip / Parcel# <br />yeler <br />k <br />ry.). . . <br />PROPERTY Owner 6;6M k /TT., et Address City kc.t 1 Phone# f'239 -41C <br />iiles. <br />C-57 Contractor Cl ric,arli.1 ,,,t Address 1225" friZ ei---/VLI City 417:..:„AttLfi.:( Zip 'A-I* Lic#551 Phone# (7/6' <br />Consultant/Sub Contractor cC7/.0`CAddress Cityby_ty; )ir Lictr Vet Phone# V 5 -12e -li.3cti <br /> , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING ( CPT. GEOPROBE, HYDR P NCH HAND-NJ GER. OTHER') <br />-bfr <br />*Other <br />COMMENTS: <br /> <br />DESTRUCTION (choose type below) <br />0 OVER-BORE <br />B PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING X-IOLLOW STEM <br />tA <br />EXTRACTION a AIR HAMMER/DRIVEN <br />VAPOR 0 MUD ROTARY <br />IR SPARGE a PUSH POINT <br />0 SOIL BORING 9 HAND AUGER <br />0 OTHER: a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE g " MULTIPLE CASINGS? 0 YES )1,,NO WELL CASING DIA: 2. <br />CASING THICKNESS ,.5M, 46 TYPE OF CASING: a STEEL 11,(PVC 0 OTHER: <br />DEPTH OF GROUT SEAL .-"S ft l& TREMIE TYPE TO BE USED:iNAU GERS HOSE <br />GROUT SEAL PUMPED: Yes it (NOTE: MAXIMUM FREE ALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: /7 r_ (//91/‘) <br />APPROX. BORING DEPTH 7 /r2O )(BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTdR CASING PROPOSED? 44 ( 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 appftçt1on and that the work will be done in accordance with San Joaquin <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: SiSio I <br />s, and all applicable California State Laws. <br /> Title/Company '--474/6.., 1/1A-p.1/11rievi---- 1143r /-42,4A-1-114 <br />Date <br />DEPARTMENT USE ONLY <br />ah-A- <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued ) ?_1)c'/ <br />Date 1+-1101 Final Inspection By <br />Date <br />Area <br /> <br />Date / <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: A1D# FA r2 _ <br />4.----' Al 1 ' I....1 <br />. ) / ' 0 -A ' 1 - 75' :. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE N-"--PIERMIT / SERMEREQUEST 0 INVOICE <br />3 5-0 ( %,9 .00 --(w?-z_ A, "17-'1°1 SR# 0 51 3 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit .Encroachment doc 9/27/00