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10/02/2001 09:13 209467' AGE STOCKTON PAGE 02 <br /> - WELL PERMIT APPLICATION FO ftM SIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MIGATION <br /> p $ Z001 ENVIRONMENTAL HEALTH DIVISION-(PHS�EHD) • UN IV <br /> 304 E.Weber, Third Floor, Stockton, CA., 95 02 <br /> ENVlR0i�4 P�i F�:A.l.i h •- - (209) 468.340 ORIBINAL <br /> PERP ITjSEFl,ICES <br /> NOT-R"1jNW1L9 PERMIT MEIRF.01 YEAR-ROM_Q.ATN^I tJET� <br /> 4ppilca8on is hereby made to San Joaquin County far a permit to construct andior Install the work descNbed. Is applicatlon is made in I ornolanea vAh San <br /> oaquin County Development Title;Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environrnalital H alth Oivislo& <br /> p Ass®I lors <br /> VELLLOoation s-20 Crose Streets1 AO we city —s�6Ck1Qzi, 7�Sb?lb parcel • <br /> )R0PEi71YOwner�P1� Address_6�l�1 Lc--.9, SAG �i city �TOGk ty� Yip 5A 10 Phw, P. <br /> :-67 Cantrac0or�rl2s'�__. ll���L �a� ,��„•address 3 a.�3 ��-4,�atrrx� ��5� Cftir�_L71p�5',[�.�lJa���az�PnCn �/�'(e�8~7Z•�� <br /> PId1� td C»� Gor Duce �t!o��/dOfo <br /> :onsult'ant I Sub ContruC*r avn " ' I{d t Ss Q�� S,+r.G.� �� p!y S r1 Lf 1'hon <br /> w <br /> ;IS Caarefnates X Y ,Ta+m-$hip „_ Range Sectio <br /> yggK BE-PERFORMED: <br /> 1 NEIN WELL I BORING(CPT,GEOPROarn.HYOROPUNCH,HAND-AUGER OTHER) 0 DESTRUCTION(d dose"a below) <br /> ) SOIL BORING# S S []C VCR-13ORF- <br /> PRESSURE GROUT <br /> Other" Grout 8ped ications- <br /> ,OMMENTS: <br /> TYPE OF_WFL INSTALLOgN TypE r,0N§jRUCTlQN SM IFICAMONS <br /> 1 MONrrORING `HOLLOW STEM D1A.OF BOREHOL3=o " MULTIPLE CASINGS?U YES ONO WELL CASING DIA: <br /> I EXTRACTION E1 AIR HAMMERIDRIVEN CASING THICKNESS - TYPE OF CASING: Q STEEL []t VC 0TH <br /> 1 VAPOR 0 MUD ROTARY DEPTH OF GROUT 8EAL ,-O' 1�. TREMIE h PE TCI Bt;usrtb: 13 A 05-RS a HOSE <br /> 1 AIR SPARGE q PUSH POINT GROUT SEAL PUMPED: U Yes `I(No (NOTE: MAXIMUM FREE-FAL DEPTH IS 301 <br /> SOIL t30aING HAND AUGER GROUT SPECIFICATIONS, r) 941b e�fil°.�� Ce�+'4enF t of c.i��Cr <br /> ]OTi iE7 �j 07HER APPROX.BORING DEPTH 0 804TED TRAFFiC SOX or O STOVE PIPIT <br /> ,CONDUCTOR CASINO PROPOSED NQ (ifYES,get specifications here) <br /> ,COMMENTS: <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCRO . CHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR 4L REQUIRED INSP CTIONS- <br /> I herefiv Certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or s,Rules and egulations,and all applicable Caiifoml/a�q . <br /> tate Law:sr <br /> SEgn <br /> ed x TitlelComparry /"t11G11 C G GCJ Cn V'10„ en�r74 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS.- <br /> WORK PLAN DATED: <br /> bete issued �`, <br /> pppllcatlon accepted By pPtts Z 02... <br /> Grout Inspac�ion 8y Date Final Inspedion B --- <br /> De*ucdon lnspedlOn Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING OIJLY: AID# FAMA <br /> PE CODES FEF?INFD AMOUNT REFAn-rED CHECK# REC' BY DACE PE.Mrr/SERVICE REQUEST-.# VWOICE <br /> p p 10- OZ. 63 <br /> C-57 WC -WAIVER_„_, C-57 Letter of Authorization to:Sign permits 9/27/100 da $/27/00 <br />