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`v7 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS,EHD) <br /> �j 304 E. Weber, Third Floor, S-tockton, CA.., 95202 ON <br /> (209) 468-3449 i <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAF FROM DATE SUED <br /> A:.,pticallz;n is here'6v:nsde to San.io,,c;wri Count,/for a peri: to con��uct and/er instal'I a wor! described. This application is made in compliance with Sar, <br /> ,oagU,r,Co my o�,Yatoprnent*Fde,Chzp:er rrt I t5.a and the Standsrts of San Joaquin County Pubiic health Services.Environmental heaith Division. <br /> �Y03 Cd'v47 G�Ub Qt's s E.sce;$ I 's <br /> V�'�LL Lucaticn ---��_-_--„ras StrGe�et�! ��`� _Ciry. �(Q"�"� ,y 7�p o� Parcel;t (� <br /> FROPFRn. ,Owner SCE9 Co'-.00i`7'""�-„dCbas ��0�L l�t``�� ity. /�1��!!� Z-,p (566/ Phane# <br /> C-5?c.cntactorpr cl�-City 7Jp. �a. <br /> �'- Lic9 7W#Phone# <br /> IfY atm Cit -ne# 7�7 <br /> CIS GJo d;-,atEs:X —,Y Township Range' _ 5eCti0n <br /> i <br /> i <br /> WORK TO EE PERFORMED: I <br /> �/ '^lEdv v:E!!_I AOF!mG(y PT,GECPROSE.HYi7ROPU`=C�t,HAND-AUGER,OTHER") j ❑DESYRiJCTION (ohooso type belmr) <br /> Y p SOIL BORING# OV�R-BORE <br /> k'A'ELL# .SP- -Am.-k" �— -!��mow' p PRESSURE GROUT <br /> "Other: Grout rpecirications. <br /> MSi3 T S7 <br /> SFE OFw-Lt RISTAI�LA"I ON TfPE CONSTR_JCTION SPECIFICATIONS <br /> I <br /> 9ru0NIT.;JR!NC- A(HOLLOW STEM. D1A.OF BOREHOLE�u_MI i..TIPLE 1-ASIr4ps [j YES P(NO WELL CASING DIA: a <br /> u E.XTR,%CTION, iI AIR PAW,;EF:u,r-RIVEN CASING THICKNIESS f��lO—TYPE OF CPAING! 0 STEEL 'APVC Q OTHER: <br /> C VAPOR 9 MLID RO'"ARY CEPTdi OF GROUT GEPL 70 6 7r TREMIE t`'r�E TO BE USEfl: Q AUGERS HOSE <br /> /YAR SPARGE Ci PI,ISH PO NT GPOLT SEAL PUMPES: 0(:'es 0 No <br /> (NOTE: Nd1AXl� FREE-PALL DEPTH IS 30' <br /> Vfl 50;L 00R!NG Q HAND Al.!G_F GROUT SPECIFICATIONS-. /7 <br /> u OTHER: _4 07tiER _ :i?FRCX.BORING t7EPTF! 3D ]'m $� Q( OLTE:0 TRAFFIC BOX or p STOVE PIP=- <br /> CONDI-1--TCR CASING PROD,--)SED? YYf RYES,list s-a-cifica ons here;: �.S- <br /> "COh'MENTS:-,�,^ I <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCR ACHMENT PERMITS. <br /> CALL THE UNIT i`v' W63PECTOR 48 WORKING HOURS IN AL7V;yNCE FOR 14LL REQUIRED INSPECTIONS. <br /> i <br /> 3 Hereby se;`ify thatjJ22xe preparsd this application; and that the Work will.be do�e in accordance with Sart Joaquin. <br /> County Ortfina s Rule an iJlatians,and all applicable California State Laves. <br /> Signed x TitlrFCompany <br /> Prin;Name i��� d G41 <br /> DEPARTMENT USE <br /> ONLY �I <br /> S.TE MAP IN UWT IV FILE,ADDRESS: <br /> r <br /> WORK PLAN DATED: <br /> Applitztion Amsspted B;r _ —Date issued 1 �3 area <br /> Grout InspecRan Py _ _Date Fina'Inspection By , Data <br /> Oestruction insoection By Date <br /> COMMENTS 1 CONOMONS: i <br /> i ACCOUNTING ONLY: 1 AID# : II <br /> i, PE CODES FEE INFO AMOUN i REMITT,L--D CHECK!F Ii!_�'D 8Y I DATE R>=RM1T 1 SERVICE REgUzST# It4VOICE <br /> C-57 CW -WAIVER, C-57 utter of Authorization to sign permi# Encroachment doc 9/27/00 <br /> i <br />