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04/15/2005 12 51 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> W be Thai d F�loo DIVISION � <br /> H Stockton, CA.95 02 <br /> S aH !O ALAS HIM- (209)488-3449 <br /> 1~NV 1RO F ARSHENt <br /> HON- EFUN ABLE PERMIT Xpw S 1 YEAR FR M D T ISSU D <br /> alicatlan is hereby mad*to San,Foaquln County for a penult to construct andlor Install the work described Thus appticatlon Is made In camPllance with San <br /> quip County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Environme�e�s sDlv]slon <br /> iVf1LL:.awttaR �io5 W. fie•. M:n 1 [ . cess street w�a city 5k Fp Parcet -� DO b�� <br /> OPERTYOwnerGf^e�r•y,I rxAca �M4 _Addres9 °6i o ,, n Cjty �,—j l�a�N Zip l/S'J —phone# 11Z6"54z-/57z <br /> ` City r�rera ip , '1/b 6 $'/ 4Y <br /> dPOI1NZ Lio#7r� <br /> TccntractoC aM� <br /> nsukant l Sub Contractor cT Sn A b Address -Soil Krlq cr�Ck Uc# <br /> i Coortiiflalt9S_X <br /> Y' .Township Rangq_ Secdon <br /> IRK M BE PEREC)RMI=ODESTRUCTION( se type b@low) <br /> !EW WELL/BORING(CP7,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) POVER-SORL <br /> I]SOIL BORING# 11 PRESSURE GROUT <br /> I]WELL <br /> har• Grout Specifications a 4 <br /> )MMENTS <br /> EgQE WELL INSTAKLATION TYRE CONSu0114 SPEC FIAATIONS r <br /> AONI MNGHOLLOW STEM DIA.OF BOREHOLE_q `�_MULT[PLE CASINGS?©YES XNO WELL CASING DIAL— <br /> --XIRACTiON! a AIR HAMMERIDRIVEN CASING THlCKNFSS &6 q as _TYPE OF CASINO. ©STEEL )(PVC Q OTHER <br /> AikOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE~TO BE USED- PJAUGERS 11 HOSE <br /> OPAR43E Q PUSH POINT MOUTSE-AL PUMPED nYes p No (NOTE; MAXIMUM FREE-FALL.DEPTH IS 30') <br /> 3OIL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> ­ <br /> OTHER__ APPROC BORING DEPTH 0 BOLTED TRAFFIC BOX Or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?-_______..(If YES,IFst specrficatrans here)_ <br /> O�Itu[ENT&• X1 tls Mw'I -2 -�1 �S - -moi 0 :901A,:9 -k-r'.6 =7-��9 <br /> • �a, d t ro <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 /> tereby certify that I have prepared this application and that the work WHI be done In accordance with San Joaquin <br /> ounty Ordinances,Ru a Ind Regulations,and all applicable CallfomiarState <br /> �Laws. <br /> Tlfierompany-_ 7'�,, " 5 C c" <br /> A18d z <br /> arc [rata �� 't -71 110°r <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADD SS: <br /> i <br /> FORK PLAN DATED' <br /> Aaoapted By Date Issued <br /> 'oat Inspection BY <br /> Date Feral Inspedlon By Data <br /> nt Ucdon fropection BY Date <br /> DMMENTS f CONVITIONS <br /> AjWUNTiNG ONLY* LAMOUWTRMrrMo <br /> t8r* <br /> ODES IEE INIFO CHl~GK# RECID BY VATB PERMIT/SERVICE REQUEST# INVOICE <br /> SR <br /> ;-57— WC _WAMP,-- C-57 Letter of AUthorization to sign permit Encrodchment doc_ 9/27/00 <br />