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FIFTH FLOOR r-G- 1 <br /> 04/11/2001 10:_28 294583433 rir in r�&R <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE 5 UNIT IV <br /> ENVIRONMENTAL HEALTH 1XVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, GA., 95202 <br /> (209)498.3449 <br /> NON-REFUNDABLE PERMIT IRJES 1 YEAR FMM OEM LSSUED <br /> Application Is hereby made to San Joaquin Cauntyfvr a penmlt to ovnsiruet andlor Instar Iha Work deaerlbed. 'this appmemon is made in eo�llance with San <br /> Joaquin County Development Title.Chapter 9-1115.3-and the Standards of San Joaquin Counts*Public Heallh Servkss,Environmental Health Division:' I, <br /> AsSessoN jl <br /> wt;i.1_Locatlon,,,_400 N. E1 Dorado Ay�a$S�tLindsay Stockton <br /> pity Trp95202 PS,.�j�.?3907009 <br /> PROPERTYOwnar Joe N uyen ,gddrm 00C�N:..E'Dorado City Stocktor;4p95202 phone4l_ 209/9'41 -7676 <br /> S <br /> s7contracoar Vironex 2110 Adams Ave. .CkyS.F. Zp 945 2p 7059 , 510/56$-7676 <br /> cta <br /> :onsultarrtlSub CorrtrarDrion Env' 1 Address 3450 E. Sprin CItyL.B.__aoP Phan 62/98'$-2755 <br /> M <br /> 315 Coardinates:X Y Township T 1 'N Range R 6 E Section 2 0—.�--- <br /> TO <br /> ]3E P✓E ED: <br /> Ew w CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHKIn p DESTRUCTION(choose We bel0w) <br /> (I SOIL BORING# OVER-BORE is <br /> p WELL# MW- URE GROUT <br /> other. Grout Speeliicadons: . . <br /> ,OMMENTS: - <br /> YPE� I SONTYPE -cmmucTiom spig—gFIGA17as TXkONITORING II HOLLOW sTFM DW.OF BOREHOLE <7 MULTIPLE CASJNGS7 AYES WELL GASINGDW.3 <br /> l crlQN Q AIR HAMMEWDRII+EIV CASING THICKNESS TYPE OF CASING: U STPEEL VC, a OTHER: <br /> I VAPOR JMZUDRQRY DEPTH OF GROUT SEAL, „ 41 TREMIETYPETOBEU D, GAUGERS ONOSE <br /> I AIR SPAJRGE T i' GROUT SEAL PUMPED; (]Yes [INo L,(NOTE: MAXMItUM MEE-FALL DEPTH IS 30') <br /> I SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: — e <br /> OTHER. U OTHER APPFiOX.BORING DEPTH C3LTE0 TRAM 0 Bt3 or 0 STOVE PIPE <br /> CONDUCTOR CASING-P_ROPOSM? (EYES.list speciticatIOns harey - <br /> :oMiulENTs: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 40 WORKING HOURS IN ADVANCE FOR ALL.REQUIRED INSPECTIONS. <br /> hereby cerci t I have preparedIs a Llcation and that the wont will be done in accordance with San Joaquin <br /> ;our i ales and Reg latiorls and all applicable California Siate LaWs. <br /> ignad TIgelCompany Hydrogeologist/Orion Environmental <br /> dnt Neme Drummond Date <br /> DEPARTMENT USE ON LY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> IORK PLAN DATED: <br /> 2pllcatlon Accepted By ' Date Issued i Area L�� <br /> rout InspecUon By. Date �� al Inspection By Data C1 <br /> astruedan inspection By Date <br /> DM9IMT51 CONDMONS: <br /> ACCOUNTING ONLY: RID# <br /> )E C GOES FEE INFt] AmouNT REMITTED cmECK IR RECD BY DATE PERMIT l SERVICE REQUEST 9 INVOICE <br /> -$7 WC -WATVER C-57 Letter of Authorization to sign permit Encroachment doe 9/27/013 <br />