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06/30/2002 14.02 2094683433 FIFTH FLOOR PAGE 03 <br /> WELL PEAMIT APPLICATION FORM SITE <br />' SAN JOAQUIN COUNTY pUBL#C HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL, HEALTH DIVISION(PHS-15"D) UNIT 1V <br /> 304 E. Weber, Third Floor, Stockton, CA.,95202 <br /> (249)48$,3449 <br /> ff0"gft&LAB.1&P ;RMIT Application is hereby made to San Joalum County for a pertnit to construct and/or install the work as ad This oppl�t�on im made in compliance with flan <br /> I Joacjuln County(?avelvpmerlt Tina,Chapter 9-1115 a and the Standa►t1s of San.loaquln Canty Public Wea119,Se Ims,Err„Imirimental Keaft Dmalon. <br /> 1NELR LacatitirtAssessoe <br /> 1 __ CMSG Street r� ` f City 7570 lPsrcem /ai/ -D 7 q-O � <br /> PROPERTY QWF <br /> or <br /> f�,e,"dress�C�1�J�_t.(NIOnJ City. abzagA <br />' C-67 Contractor dress City 1t ASL+ Zip .c# tk)70gPhonef <br /> Constaltartt!Sa,h Contractor n/G, MISS If I�/y.4� :— � %4(0 <br />' dIS Coordinalea- Y Township Rango Sea6o <br /> o K FO D <br /> )KNEW WELL I BORING(OPT.GEOPRoag,HY0fIOP1LNCH.' BAND AUGER,OTHER-) U DESTRUCTION(chodse type below)d SOIL BORING# _ Q OVER-BORE <br /> JKWEIL 13 PRESSURE:GROUT <br /> 'Other �Grout SpaciHcatlonsl <br /> COMMENTS; <br />' TYPE OF WELL !fit RELATION TYPE P—aNSTRUCTION S EC FlCATIONS <br /> PONITQRING pCkot.Low STEM DIA.OF 9QRrzHOLE MULTIPLE CASINGS9(I YES"KNO WELL CASINQi DIA Z r_ <br /> d DCI RACTION AIA HAMMER/DRIVEN GA$1Nti'i THICKNESS SC#i} _ TYPE OF CASING- U STMEL .01*,VG 13 DTHER__ <br /> Q VAPOR U MUD ROTARY IDEPTH OF GROUT SEAL h• // ' TREMI£TYPE TO 8E USED: #1UGFRS 11 HOSE <br /> HAIR SPARGE (]PUSH POINT GROUTSEALPUMPED BYeB P'ia (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> L t30fiENt`a (i HAND AUGER GROLfTPEGIi IOATIONS <br /> a OTHER-.__ fl OTHFR APPROK BORING DEPTH 7' _ QLTCO TRAFFIC BOX or' lJ STOVE PIPE CONDUCTOR CASING PROPOSED?�(if YCs,psi spsolflcations here)__ _ <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REOUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Orth noes, Rules an Aegu tions,and all applicable Califomia State Laws. <br /> Signed G m Title/Company (t e&,L 4 <br />' Pont Name V1 to <br /> DEPARTMCNT 129E ONLY_ <br /> SITE MAP IN UNIT IV FILE, ADDRESS:._ �:/!;- <br /> WORK <br /> WORK PIAN DATED: pp <br />' Application Aooepted BY /Tats issuedir 1-3 c2 D-a- <br /> Grout <br /> Grout lnspamon 8y Date Final Inspection By <br /> D mcion Inspectloopy Date <br /> COMMENTS I C0NDITIONt3• <br /> Al'OWNTING ONLY AID# <br /> IC q h <br /> FIEF CODES RES INFO AMOUNT FIEMITTLD CHECK# REWD BY DATE PERMIT/SERVICE REQUI18T 4 INVOICE <br /> C-57— WC -WAIVER. C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />