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GEOLOGICAL TECHNICS PAGE 02 <br /> 11;10/2000 09:54 2095385852 -lkvw/ — .` <br /> 09/02/2000 09:42 2094693433 FIFTH FLOOR PAGE 03 <br /> WELL. PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (RHS-EHD <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> N0N gEFUNDA5LE PERMIT EXPIRES 1 YEAR FROM PATE ISSUED <br /> pplication is hereby made to San Joaquin County for a permlt to construct and/or install the work de5rr4had. This application is made In compliance with San <br /> oaquin Ccunty Oewe!opment Title,Chapter 9-1115.3 and tht Standards of Gan Joaquin County Publtc Health Serv!cee,Environmental Health DiVFsion. <br /> v� �a <br /> Assessor's>'d <br /> CrasStre1CV-,Ck W�- City Sit)�J' � Zipps1c-j Parcel# <br /> TELL LocatioG <br /> 'ROPERTYOwner �rwh0 :i .Address JQCityStOc-tJn <br /> Zip i5Z� Phonzn <br /> }�t1 l3� S 1 i Q:O \atg zi slry' l�ic#1 g0�} Phone?t�l�'-�-1�- <br /> :-57 Contrac=WN %W e^ \a:��Address '+L Cb per-^ _1 <br /> :onsuitant/Sub Contractor Address �CItY u PhaneH <br /> SIS Coordinates:X <br /> Y Township Ranga^ __Saoslon <br /> YORK TO BE P_ FORIMMU <br /> (NEW WELL/BORING(CPT,GcOPROBE,HYDROPUNCH,HAND-AUGER.OTHER") 13 DESTRUCTION(choose type below) <br /> SOIL$ORING <br /> 00 OVER-BORE <br /> WELL `� k l01 p PRESSURE GROUT <br /> Y�ELL 9_ '�' L� 1 t GROUT SPaCIF:CATION <br /> •other: h_ <br /> :OMIVIGNTS: h�� ��i r` O-o__� tt p <br /> 0.k kC,6 Rc� B <br /> A '�0 lr. rro aC+s $`epi <br /> CONSTRU".014 APECIF EIONS r� S mN <br /> PYPE OF WELL INS�LLATt013 TYPE <br /> �'NtdNTrORINO p HOLLOW STEM DIA.OF BOREHOLE—MULTIPLE CASINGS?0 YES Q NO WELL CASING DIA 0 <br /> ]EXTRACTION 1)AIR HAMMER/ORIVEN CASING THICKN=SS TYPc OF CASING' 0 STEEL B PVC BOTHER: <br /> ]VAPOR Q NIDD ROTARY DEATH OF GROUT SEAL, TREMIE TYPE TO BG USED: 9 ANGERS DHOSE <br /> ]AIR SPARGE a PUSH POINT GROUT SEAL PUMPED, 0 Yes 0 No (NOTE= MAXIMU M FREE-FALL DEPTH IS 30') <br /> ]SOIL EORING 0 HAND AUGER GROUT 5PECIFICATION <br /> ]OTHER-..V OTHER APPROX.BORING DEFTA D BOLTEO i RAFFIC ons hare}; <br /> or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list speGTications <br /> :a M MENT3; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMIT <br /> hereby Certify that I have prepared this application and that the)work will he done in accordance with San Joaquin <br /> ;.ounty Ordinances,State Laws,and Rules and Regulations of the San Joaquin County, <br /> *CALL TH UNIT IV SPE TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Title/Company t�—, mO,r�O�S�Q.� <br /> Slened x ) ` � <br /> �rintNama <br /> a 0 0 Lo, �� , Date j — r 0 O Flo ' 1 k <br /> 1 3 'l 11 po <br /> SITE MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED �} si4e ce 1013�6° <br /> DEPARTMENT SE O <br /> Data Issued — _ Area Z� <br /> �pplicallon Aocepted BY Date_____,..^._ <br /> Brous Inspection By V Date ! r Final Inspection By <br /> )us,rucGon InePottlan By Date <br /> yL w _ <br /> 1OMh16KTS!CONDITIONS: t'r c+ii+ rt 1 rt S <br /> S I VIUI <br /> ACCOUNTING ONLY: AM# <br /> FE CODES PEE INFO AMOUNT REMITTED CHECK RECD!IY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> it Encroachment doc_ 7/17l0e <br /> 57 WCIWRIVEP C-57 Letter of Ausharizatlen to sign perm <br /> C- <br />