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05/61/2662 08 47 2894683433 FIFTH FLOOR PAGE 02 <br />,,,t ;r►,tzt �,s� ! ��, WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> 2� n2.58 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH QIVISION (PHS-EHO) UNIT IV <br /> �� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NQN•RFFUNDAS E PERMrr EXPIRES I ytr;M FRoM I ATE IS9jjEp <br /> Application is hereby made to San Joaquin County for a permit to conatruot andror install the work deSoribed. Thia application Is made in compliance with San <br /> Joaquin County Development Tina,Chapter 5-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division <br /> WELL LocatJa O"e _ -S7— Cros Sweet S ZJp P Assessor's <br /> PROPERTY OwnerSuety $'l ll Ziphone# <br /> C-67 Convector /✓ dres8 City Zip. Loren hone# •.S=3/�"- <br /> Consultant/Sub Contracto _ <br /> �tY � Lloi► phone#, ffE AV'-V 29Z' <br />=Coordinates X ,Y ,Township Range Section_ <br /> NoR( OBE RF MEQ- — <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HANDAUGER,O-rHER•) 0 DESTRUCTION(choose type below) <br /> []SOIL 130HING# <br /> [I WELL 0 OVER-BORE <br /> Vdier Grout S 11 PRESSURE GROUT <br />:*MMENTS Specifications <br /> qtr OF WELL INSTALLATION TYPE Q.0-.NMUPjI0N SPECIFICATIONS <br /> MONITORING )(HOLLOW STEM DIA OF UOREHOLE /O" MULTIPLE CASINGS?9tyEg []NO WELL CASING Di/0. orf <br /> J EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS_ TYPE OF CASING []STEEL 'PVC I]OTHER. <br /> I" 0 MUD ROTARY DEPTH OF GROUT SE4L� J TREMIE TYPE TO 13E USED XAUGERS [I HOSE <br /> ARGE 0 PUSH POINT GROUT SEAL PUMPED 0 Yes I]No (NOTE: MAXIMU FREE-FALL DEPTH IS 30') <br /> I SOIL BORING HAND AUGER GROUT SPECIFICATIONS / rIf'l' <br /> E OTHER OTHER_ I L ,.g <br /> APPROX BORING DEPTJkSOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? d (It YES,test specifications here) <br />;AIV MENTS- <br /> to® r.✓ _ ►_ r <br /> NOTE: OFFSITE BORINGS REQUIRE AcCESS OR ENCROAC WENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that tate work will be done In accordance with San Joaquin <br /> aunty Ordinances, I s and Regulations, and all applicable California State Laws. <br /> gred ' Title/Cornpany, <br /> Int foams G <br /> G <br /> DEPARTMENT USE ONLY date <br /> ITE MAP IN UNIT IV FILE,ADDRESS: ;—;' 0 5 C - 54tep- <br />'ORK PLAN DATED: z 2-/v Z °°.. -- <br /> -026 <br /> kation accepted By ate Issues O Z Aura_ <br /> out Inspeaton By ste Anal Inspection By ate <br /> oivobon Inspection By Date <br /> wiff1wis f comornoNs. <br /> NCS ONLY AID# <br /> Cana <br /> E OCDES FEE INFO AMOUNT REMWMD CHECK# REC'D eY !DATE PERMIT J SERVICE REQUEST INVOKE <br /> 3�0 Tb�rD=, 5zo3`�9 � � T bZ <br /> 57 WC -WAIVEl2 C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />