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12/03/2664 16:41. 26346E 13 FIFTH FLOOR -PAGE 62 <br /> nO {� �1 r�J WELL PERMIT. APPLICATION FO1kM SITE <br /> W il MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> BNGOi`,'"j hNT HEAL,H 304 E. Weber, Third Flcor, Stockton, CA-, 95202 <br /> 1'EFS��ITCCE ��ICCS (209) 468-3449 <br /> ON-REFUNDABLE PERMIT EXP.IR 5 1 YEAR FROMIDATE ISSUEa <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 Tide,Chapter 9 1 15.3 and the Standards of SaniJoaquin County Public Health Servicas,EnYronmentO Health Division. <br /> WELL Location 22 LL hit, ,r� craw Street ' city zip'l p el ibis-0s -59 <br /> PROT hnmA e�Zp►c.i/�. Lt� ty .tGrr�N Zip Phone# e �t-1-0144 <br /> PER �� Address `IO � - r'Ci <br /> ��``nn Vi/OY►d �I J`1� City�1•ty icA Zlp9y5o is 6o' &l Phone# 4 -Rn'�D <br /> C-57 Contractonl i� �tt� R t�}yt3 _Ad <br /> ConsultantJSubContraejPi?onl��h1t1—llSat+lrlG' S-Address �Nt� C CityQ ��flc# P>�dne �� -� O <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: pESTT2UCTION(choostselow} <br /> XNEW WELL J BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) a OVER-BORE s a type type <br /> p SOIL BORING# <br /> -XW ELI.N - n PRESSURE GROUT <br /> -Other. �pF_ �y �cp ` S - _Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC FIC TION <br /> MONITORING HOLLOW STEM 01A. .OP BOREHOLE-9 MULTIPL.ECASINGS?[IYES�NO WELL CASING DIA: Za <br /> fl EXTRACTION d AIR HAMMER/DRIVEN CASING THICKNES9�lAP� TYPE OF CASING,: p STEEL PVC OTHER: <br /> [I VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL 3!J TREMIE TYPE TO 13E USED: "AUGERS Q HOSE <br /> II AIR SPARGE la PUSH POINT GROUT SEAL PUMPED: p Yes KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL E30RING D HAND AUGER GROUT SPECIFICATIONS: rti�BOLTED TRAFFIC SOX or Q STOVE PIPE <br /> d OTHER: _a OTHER-_ APPROX.BORING DEPTH��� <br /> CONDUCTOR CASING PROPOSED? �,Jn,_(iFYE3,list specifications hen:): <br /> `COMMERITS: 4&Q WfU <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 Ordin noes, Rules and Regulations,and all applicable California State Laws. <br /> Signed <br /> TitlelCompanyt�her "C'7eo �161�AZ01J ►�1�^R�X11�i � <br /> Date,2.rl�7 l0�✓ - <br /> Print Name r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> 1 <br /> WORK PLAN DATED: <br /> Application ACCepted Byt t (j ate issued <br /> Grout Inspection By ��+ Area <br /> Date nal Inspection By L Dat Q/ <br /> Destruction Inspecdon By ate <br /> COMMENTS I CONDITIONS <br /> ACCOUNTINGONLY: Ald# FArg <br /> PE CODES FEE INFO , naurrrGt�xEMITTED CHECK# RtG'D sY oaTE PERMrf1 SERVICE REQEJEST;� INVOICE <br /> yQi <br /> C-57— WC -WAIVER— C-57 Letter of Authorization to sigh permit„ Encroachment doc 9/27/00 <br />