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03/29/2001 12: 14 209488343"' FIFTH FLOOR ` �' PAGE 04 <br /> .WELL PERMIT APPLICATION If OR SITE <br /> `' MITIGATION <br /> iSAN JOAQUIN COUNTY PUBLIC HEALTHSERVICES <br /> !; UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION '(PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ! ,' <br /> FILE COPY <br /> NON-REFUNnARLE PERMIT EXPIRES 1 YEAR FROM DAT5 ISSUED <br /> ! Ilcatian is hereby made to San Joaquin County for a permit to construct and/or Install the work dasobed. This application is made in compliance with San <br /> ii juin County Development Title,Chapter 9-1115.3 and.the Standards of San Joaquin County Public.Health Services,Environmental Health Division. <br /> ! 'F 95z� Assessor's / <br /> _LLocation$RoQk5)DE Cross Street BROOKSI city STbCKTOIy zip Parcel# <br /> r'dwrsr codtrJ�WreRS C00N OF. r-5 AUG OOV06 s510 i <br /> )PERTY owner C IrZ OF O OYAddress 2 500 NRVY DR. City STaCi�Tol1� zip �Z Pnorle#(Zo4�93��$322 <br /> -" <br /> i' 7 Contractor 5pcc T/2um _Address 36 W f 6W M Dk city 5TO6K1_0yZip g5Z4 Lie#SI?10 Phone#(269 4166-8712 <br /> ' XPCORR rid r ,� i <br /> isultant1Sub Gontractnr�MP �ES,�F/Pd CK� Address/l7 /NG[f At sm 3zciltY14��'r�fEie# Phan.#(?25)133-Z9 <br /> - , 1 , l3 3 <br /> C Coordinates:X J�S I ,Y 2 !�- y/ Tc--snip �� JY Range R Section <br /> RK TO BE PERFORMED: <br /> EW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND UG ,OTHER ) Il 'I 17 DESTRUCTION(choose type below) <br /> Q�OIL BORING# 1 2 t I �]OVER-BORE <br /> SWELL# 1 �P� 1 r1 N Grouts Specifications:�5� POe�Cf1�� NE - �E,y PRESSURE��T N7v�ir <br /> C- <br /> her; PrC'?ongrck P_�-1--- w ZL Ae w2zgc4cp / .52 p <br /> MMENTS: 11 ;! <br /> i <br /> sE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f/ <br /> 1144OLLOW STEM DIA.OF BOREHOLE_:MULTIPLE CASINGS?11 YES _"O WELL CASING DIA; <br /> XTRACTION 0 AIR HAMMER)DRIVEN CASING THICKNESS SC - 0 TYPE OF CASING_ Q STEEL A'PVC I7 OTHER: <br /> 'APOR p N1UD ROTARY DEPTH OF GROUT SEAL '`1L. 19 f 4EMiE TYPE TQ SE USED: I]AUGERS p HOSE <br /> ,IR SPARGE R PUSH POINT GROUT SEAL PUMPED: 0 Yes MNo (NOTE : MfAXIMUM FREE-FALL DEPTH IS 30') <br /> TOIL BORING HAND AUGER GROUT SPECIFICATIONS: 7wPeRTLHwD ,,6.47 CEM T / /3E�t/TON r re <br /> )THER. FA :t^ Q OTHER APPROX_BORING DEPTH Q J 3 s��$�= is BOLTED TRAFFIC BOX or STOVE PIPE <br /> € CONDUCTOR CASING PROPOSED? t,10 (if T S,list specifications here). <br /> WME'NTS. I` <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FPR ALL REQUIRED INSPECTIONS. <br /> tereby certify that I have prepared this application and that the work will b- done)in accordance with San Joaquin <br /> ounty Ordinances,Rules and Regulations, and all applicable California State Laws, <br /> tned x c- Cf[ TiwCompany F- <br /> I <br /> ,nt Name l r Date Z <br /> DEPARTMENT USE ONLY I <br /> ITE MAP IN UNIT IV FILE,ADDRESS: /`S. i /•Sd L�/L 7� <br /> j 'ORK PLAN DATED: Z / *t 0I ! <br /> i ii <br /> :plication Accepted By Date Issued 4 � � A a Q <br /> w <br /> rout Inspection By Date Final Inspection By Date <br /> .snuction inspection By Date <br /> OMMENTS 1 CONDrrIONS: IL <br /> ACCOUNTING ONLY: AID# ! <br /> FE CODES FEE INFO AMOUNT REMrfTE1D CHECK# REC'D BY DATE I PER MITI SERVICE REQuI=ST# INVOICE <br /> 25 � <br /> :-57 WC -WAIVE=R C-57 Letter of Authorization to sign permit Encroachment dot - 9/27/00 <br />