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11/30,'`21700 15: 21 2094683431 FIFTH FLOOP. r I L ire T <br /> P Y <br /> WELL PERMIT APPLICATION FORM SITE <br /> - MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHE) <br /> APR - 2 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 w� <br /> �TIL i <br /> LL NON-REFU_NDAHLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ::Plication is heraby'made-6 San Joaquin County for a permit to construct andlor install the work described. This appiicatior is made in compliance with San <br /> 7aquin County Development Title, Chapter 9-11153 and the Standards Of San Joaquin County Public Health Services, Environmental Health Division. <br /> 11 I ASv85SOr'S <br /> TELL Location I tpO j S. �� D(xoAO -51, Gross Street �. City dXklon--zip 95�OV Parcel# <br /> ROPERTY Owner C-�eet� ) 7 GWIJJLatl_ a�.Address lcSS�CQ(nell Lam' • city i t,r1ocL Zip S.35Z Phone# <br /> -- rr IIII � <br /> f tl � K - 3{o City �! {dip7� Lit# i ,t. Phone#��a as <br /> -57 Contractor card pr+ lAddress �1 ,, <br /> onsultant/Sub Contractor Address MLA-if�� k\C� 7 FICGi f �C <br /> ic# `�D" Phene4-4 � 2-'01 b <br /> IS Coordinates:X Y ,Township P,ange Section <br /> 'ORK To 13E PERFORMED <br /> `lEW WELL 1 BORING(OPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ,DESTRUCTION(chcase type below) <br /> {] SOIL 130RiiNG# } OVER-SORE <br /> Q WELL# )LPRESSURE GROUT <br /> ]cher; Grout Speclfications: <br /> OMMEINTS: Nti r - I c cry <br /> ePE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA_OF BOREHOLE MULTIPLE CASINGS?p YES ONO KNELL CASING DIA: <br /> EXTRACTION p AIR HAMMEPIDRIVEN CASING THICKNESS 'TYPE OF CASING: []STEEL 0 PVC 0 OTHER,.- <br /> VAPOR <br /> THER,VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO 8E USED: Q AUGERS a HOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING (]HAND AUGER GROUT SPECIFICATIONS: <br /> OTHFR, []OTHER APPROX. BORING DEPTH I]gOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (ir YES,list specificaticns here): <br /> :OMMENTS: ±2LLQLAS Cl <br /> -t�v_ f 1 . <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 /> 7ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances Rules a d Re mations, and all applicable California State Laws. <br /> 3nedsrn 'i� .G ' - G G <br /> int Name G7. 7 Data <br /> DEPARTMENT- USE ONLY <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> 'ORK PLAN DATED: 3- Zed v //�. <br /> iplleatipn Accepted By date Issued C)6 �/l Area <br /> out Inspecton By Date Final Inspection 6y % <br /> �atruction Inspection By Date <br /> :WMENTS I CONOMONS: <br /> ACCOUNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK 4 RECD BY ❑ATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35oi W1) �0. � Z•d 25 <br /> -57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/90 <br />