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FiFIH FLUUH PAGE 03 <br /> WELL PERMIT APPLMATION F0 <br /> 0 <br /> d1 <br /> SITE <br /> << �� MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA_, 96202 <br /> (209) 468-3449 <br /> `t `\ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iplication is heat'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 /> )aquin Count�evelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> I S/ / Assessor's <br /> ELL Location '11'7 .�., A; Cross Street R4.t n��nA Icity 5toc�C-t'dv1 Zip 96 2b� Parcel#_ r.6 -02Q� 3 <br /> 30PERTYOwnert�lnpL,XA,,,on4,�N` t� drEess��? � ]SC. �y.rnU W 1 Sfa <br /> /� �-—n-- 3 p C ty t zip g 2v Phone; &)1,8 3-3 <br /> •57Contractor_MArCQ,C,,�=ro��rtle.t(�lddress 2C)52- I�.�[i5K,,JA. CitySe,\�LeANJ2:,:1p94677Lic -f4432-9440 <br /> ins_ nt!Sub Contractor. cstit—, Address Z lG l W e k 5Je`6. - Citydit k( Uc# Phone 5r a 9](-96g 5 <br /> v: e-7c6S Coordinates:X Y Township Range le C— Section '73 <br /> JRK TO BE PERFORMED: <br /> VEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# )kPRESSURE GROUT <br /> ther: Teyt V&v6k-U un!1 s +'n' r Lx Grout Specifications: <br /> )MMENTS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 'diva +`l p e 5 t 4rr(ct5 i�y 6r.� M u�{ P�e / Cd 5 -J5 <br /> AONITORING 0 HOLLOW STEM DIA_OF BOREHOLE ,MULTIPLE CASINGS?)(YES flNO WELL CASING DIA: <br /> XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL -PVC []OTHER: <br /> 'APOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; [I AUGERS HOSE <br /> UR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: *Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> !OIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> )THER: fl OTHER APPROX.BORING DEPTH 3g-Ee, -46 '�t.�.tOLTED TRAFFIC BOX or. STOVE PIPE <br /> / CONDUCTOR CASING PR/OPOSED? (if YES,list specifications here): <br /> )MMENTS• Se Le( e ,-6* M'tp. � IL—t-4Z -! -C*. <br /> Pry � a�- 't 5 ZOc`- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS ORE CROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> areby certify that I have re ared this application and that the work will be done in accordance with San Joaquin <br /> unty Ordina ces, Rul a egulations,and all applicable California State Laws. / <br /> red x /� / Titie/Company_ pr i C �L'Cs eo(Griy`r /p�{�5G�1t,� U�ti P�_�q <br /> t Name �MC{��ic F� C . `C iyL Z tom— Date_ /g�D J`�`ei•�I L J'1c . <br /> DEPARTMENT USE ONLY }} <br /> 'E MAP IN UNIT IV FILE,ADDRESS: 3 4 3 � W c <br /> )RK PLAN DATED: <br /> icaltion Accepted By. Date Issued_ 4 4 I 2 Area ` <br /> t Inspection By Date Final Inspection By Date <br /> -ucrion Inspection By Date 3 2� <br /> TENTS 1 CONDITIONS; <br /> iuNTING ONLY: AID", FArtf <br /> ,S FEE INFO AMOUNT REM11T ED CHECK# RECD BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> 'C -WAIVER C-57 Letter of Authorization to sign permit - Encroachment doc 9/27/00 <br />