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68/30/2002 14:02 2034683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SI1`E <br /> SAN JOAQUIN COUNTY PUBLIC; HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-RHD) UNIT IV <br /> 304 E. Weyer, Third Floor, Stockton, CA., 95202 <br />' (209)488-3449 <br /> NPREREMNIDARLEIERMIT IRE9 DATE IMUED <br /> AppliCaftiOn is hereby made to S21n,lowpfn County for a permitto wnstructAnd/or install the work described. This appfcabon is made In compliance+nth San <br /> Jaagc+>n County D WIOp(neni TWO.Chapter 8-1115.3 and the Standards of San Joaquin County Public Health SoNces,Environmental Health Division_ <br /> WELL.Locatio 11�C Croas Streets.4f,jCac..*j C,ty p 4V 06 Pa ceE�1�-617' <br /> PFIOPEATY Vwner TIZS Fess 112_ urf10-1 CO ... CIb <br /> hone <br /> G57 Contwacborrt�t'rttir�2r- lw�ddressMY4v k� CitY�UZililtc ��D7phaneR <br /> 40t�SuIWnt l Sub Contractor dress lea M kticE r, Ccty�� Phon y ��S B OO_ <br />' WS 0wronates• Y _ 'Township Flange Section . <br /> MMIK O 619 PARFORMID: <br /> EW WELL/BORING(qPT.GEOPRbBE HYDROPUNCH,H"-AUGEF3 OTHER') 1)DESTRuOTION(choose type balow) <br />' B SOIL BORING 4 <br /> 4 OVER-80f le <br /> 'Qih�t VI/E1L14 W' E.--g 4yrc,�s D� PRESSURE GROUT <br /> COMMENTS f,Lj loy / grout spedticaTions <br />' HYPE OF WELL INS{' Lt.ATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )dADNrrORING )0I0LLOW STEM DIAL OF BOREHOLE f+ MULTIPLE CASINGS?u YES-*rNO WELL CASING DIA: art <br /> Q EXTRACTION II AIR HAMMEIVDRIVEN CASING THICKNESSS IID TYPE OF CASING A STEEL )(PVC BOTHER-_ <br /> B VAPOR Q MUD}NOTARY DEPTH OF GROUT S /A'� 1� TREMiE TYPE TO SE USet7 WAUGERS [I HOSE <br /> (IAM SPARGE 0 PUSH POINT GROUT SEAL,PUMPED WYes a No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) _ <br /> IP&MLSORING--- B HAND AUGER GROUT SPECIFICATIONS u <br /> 13 OTHER_f1 OTHER APPROX BORING DEPTH �� WhOLTED TRAFFIC BOX of n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NO (if YES,1431 specificattons here)_ <br /> "COMMENTS, <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord" nces,Rul nd R gulations,and all applicable Calffornia State Laws <br /> feigned TdlelCompany ���°S � n� ✓�'�` - _� <br /> Print Namee-VWI-e4� �-- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILr=, ADDRESS:--E11-! tom. <br /> WORK PLAN DATED: <br /> Appt4eation Aeooptod By Date Issued 41�_- Area___ _ „ <br /> i Grout Inapectron Sy Date Flnal Inspect,On By Date <br /> destruction Inspection By Dale <br /> COMMENTS/CONDITIONS. <br /> FA101COUNTINQ ONLY Alp# <br /> epe�rr <br /> OD�ES FEEINFO AMOUNTREMI'tYED CHECKIf REC'D BY DATE PERMIT i SERVICE REQUEST'# INVOICE <br /> 5tfi i •oo I� G� $ o d '�- <br /> C-57 WC -WAIVEP, _ C-57 Letter of Authorization to Sign permit_ Encroachment doc 9/27/00 <br />