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PAGE U-� <br /> e9/15/20ee e9:36 209466-3 FIFTH FLOOR <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> H DIVISION {PHS-EHD) <br /> ENVIRONMENTAL HEALTH 95202 <br /> ENV Weber, Third Floor, Stockton, CA., <br /> 304 E. P <br /> (209) 468-3449 L <br /> 11:5 1 YEAR FROM CATE�ISSUE P ntion is made in wmP1!3n1:1e with San <br /> �de�; <br /> NON-REFUNDABLE PERMIT EXPIRES _Hbed. This aPPIII <br /> r instill 6 r Health Division. <br /> to construct i Environmental He, <br /> kppiicatlon is hereby made to son Joaquin Go'-., PF' ­"6;,dad1 of San Joaquin county Put)oc Health SeZap <br /> lviOes Assessor's <br /> Joaquin county Development Title,Chapter 9-1115.3 and the 'j-\j�P"P­p 17#4" r� <br /> CL_')G A city 570r--LP- <br /> -T Gross Street- 14(a 7 <br /> NELL Lot ban CityPLEnwTor� ZI egg <br /> q '5T 5 <br /> L_ # --712-35-30 <br /> Address %Lt <br /> PROPERTY Owner RiFewp"I I t'4C - VA '6`f"' Phone <br /> �Zo t-1- Address -8!53- 1800 <br /> y <br /> P h o n e#13 <br /> C:.57 Contr3etar—ELS_CA 3035-�� Lg�CityjZANCt+0 Llc#_� <br /> Add <br /> res$ <br /> Consultant Sub Contractor w5j: GlEol izA Township <br /> GIS COohjjnatest <br /> WORK To BE PERFORMED: DESTRUCTION(choose We below) <br /> EOPROBE HWROPUNCH,HAND-AUGER,OTHER*) 1.1 OVER-BORE <br /> NEW WELL GPT, 1+ U PRESSURE GROUT <br /> IN <br /> (e5x ING# <br /> 0 WELL# GROUT SPECIFICATIONS7Fjac <br /> *Other'. CC-Al <br /> r <br /> —;>I 71E <br /> _-A(,,t -- <br /> GOMIMENTS: N. 0 Kl"JOL-"f'� 'cr-j' jj,jA-T1C)\J Alit mw�7ik��� <br /> STkU- <br /> EC <br /> E�i ' S <br /> PECIS ATIONS <br /> CONSTRUCTION DyFS 13NO wELL CASING DLA:_ <br /> INSTALLATION TYPEIt MULTIPLE CASINGS? <br /> Lit�F �LL la HOLLOW STEM CIA.OF FBOREHOLE_ [IsTr=5L IIPVC OTHER: <br /> [I MONITORINGAIR HAMMER/DRIVEN CASING THICKNESS_._ TYPE OF CASING: ! n AUGERS allosr- <br /> a EXTRACTION MUD ROTARY DEPTH OF GROUT SEAL .. TREMIETyPETOBEUSED - DEPTH IS 30') <br /> a VAPOR 0 pUSH POINT GROUT SEAL PUMPED: 0 Ye, J3 No (NOTE: MAXIMUM FREE-FALL DEP <br /> AIR SPARGE UT SPECIFICATION W er-)-v <br /> SOIL BORING a HAND AUGER G 0 D TRAFFIC BOX Or STOVE PIPE <br /> AppROX,BORING DEPTH 4 '5 0 BOLTED <br /> list specifications here)' <br /> a OTHir CONDUCTOR CASING PROFOSED?_(If YES. <br /> VL F: <br /> COMMENTS- '2'0t-t'_'Gf> W%LA— K ENaROAC�HME�T PERMITS <br /> NOTE: OFFSITE OFFSITE BORIN(.133S REQUIRE - - — _in=NncWSan JoaqU.... ncWSan Joaquinared this application and that theworwilcc <br /> I hereby certify that I have pre and Regulations of the San Joaquin County. <br /> County Ordinances, State Laws,and Ru.les a <br /> CALTHE UNIT IV INSPE OR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> IpAv,3&_-X- <Sa�A-OQ LST (G3 a-'Twrtj S <br /> Title/Company <br /> Signed x <br /> PfintName <br /> - <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> D PART SE ONLY A <br /> ry D <br /> Date issued <br /> Application Accepted By Date.Final insPectiOnDY , <br /> Grout inspectionBy <br /> Destruction Inspection BY Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING IONLY: "AID# <br /> RECID BY DATE PERMIT I SERVICE REQUEST 4 INVOICE <br /> PE CODES FEE INFO AMOUNTREMrTrTED CHECK# <br /> 210 IL-1513 <br /> C-57, WC/WAIVEP— C-57 Letter of Authorization to Sign permit Encroachment doc-:= 9/12/00 <br />