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02/23/2001 10.05 2094583433 <br /> FIFTH FLOOR PAGE I32 <br /> WELL PERMIT APPLICATION FORM SITE IVIITI�ATI�;r <br /> SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES �-� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIR,FA. S YEAR FROM DATE ISSUED <br /> jircatlon 15 hereby made to San Jbaqurn County fora permit to wristrud and/or In81all the work de3enbed Thrs app[rtaUon rs made In compliance with Sao <br /> tqutn County Development Tyrie Chapter 91115 3 and the Standsrds of San Joaquin County Public Hoalth Services,Environmental Health Dlvrsron <br /> p,ssessors 22.1-I <br /> LL Locatlor I`116 4f4kPy 0-I Gass Street City Zip Parcettl_���jj2Q�. _ _ i <br /> 10FERTY Owne Olt �� Address ��Q Ci r c" Zip��lzone0:L/4 JC7 <br /> 57 Contractor I + Address_ $Sf? Rivslr Ra City .o i 21�4$'71 Lie# Phon*1$ o - M-L P 0 <br /> onsultant I Sub ContractorAddress r c.&ISM Cty. 3vS '� Lira! Zz!LF'>7ontVF �27�5�f ��fky <br /> IS Coordinates X Y Township Range Secdon <br /> 1ORK TOLE PEIZFOR,til E_D <br /> j:J4EW WELL 1 EORING I CPT GEOPROBE HYDROPUNCH NAND AUGER,OTHERI ll DESTRUCTION(choow We below) <br /> It SOIL BORING It p OVER.501:t1z <br /> ,�W£LL P /V11+U- _ 0 PRESSURE GROUT <br /> Oilier. ._,. � � r Grout Spedfirabons <br />:,QMMENTS <br /> TY?E OF YtlfLt INSTALLATION TYPE CQNSTRtaCTION SPt:CIt 1CAT1aKS fI <br />,1MONITORING � HOZLOW STEM DIA.OF BOREHOLE,�� MULTIPLE CASINGS?a YESNO W ELL CASING DIA_2„L <br /> IV1CTION 0 AIR HAMMF.PMRiVEN CASING THICKNESS dint O TYPE OF CA5l11G. Ii 5TE L kf-VC (]OTHER <br /> 0 V R p MUD ROTARY DEPTH OF GROUT SEAT. C TREMIE TYPE TO BE USED p AUGIrRS ;*OSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED Yes p No NOTF M2IUUM FRE-FALL DEPTH IS 301) <br /> d SOIL BORING U HAND AUGER GROUT SPECIFICATIONS 4Y' <br /> f&jtA it -- - T <br /> OT►i6R rl OTHER APPROX BORING DEPTH t OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSE0?_y_0 (if YES.list specifications 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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi non , les anaSegfj tions, and all applicable California State Laws <br /> �� <br /> Signed x 7lde)Comyany_. <br /> Print Name Date ,/lo%� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Ay/10,� 30 <br /> WORK PLAN DATED, <br /> Application Accepted By Date Issued Area <br /> Grout Inspection fay gate Final Inspection By Date <br /> Destruction Ins 2aan By pate <br /> tOLINTING <br /> ENTS l CONorrIONS. • ""s ONLY AID#ODES FEE INFO AMOUNT REmrrm cmEci(s FtFC'D SY DATE PERMIT I SERVICE R€QUEST 9 INVOICE <br /> D <br /> C-57 WC,-WAIVER— C-57 Letter of Authomotton to sign permit Encroachment doc_ 9/27/00 <br /> 209468343: gang pap <br />