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0506 '02 09:09 ID:CTE FSCONDIDO FAX:760-746-9806 <br /> 05/03/2002 08:],8 • PAGE 2 <br /> 209458 FIFTH FLOOR <br /> PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQVIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> pplloAtlon is horpby ntadQ to Snn Joaquin Coun .fora XP H 1. E COPY <br /> aaquin County bcvelopment Title,Chapter 9.111 ,3 end d efSt daro of Sari dorIn CPu2li the n0i d@scrfbed. This®pp)Ication Is trade to oompll�nCs with$in <br /> MLL Location o S Joaquinb Environmental Health DopartmenL <br /> Cross Street Asaos30es <br /> ROpemOwner iV�� >> dress �a � crly ' Ip5SL� I —paralls- 16 �.4Zrr�3 <br /> A AN ' I .1 ��<<�u -� I <br /> -57 Contraetoe"*e a� tS�� w ddrQ <br /> x ti '"a4� p� 2 have �/6• �. ^til" <br /> —�__CttySt. c •r� ZIp�jSLlf Llc�t oi2�Phone# tog a'/4 111 <br /> onsultent!sub Contralto Address 2-`►Z W•(-',IL. ,lr (_= - <br /> IS Coordlnateo:X CIEs <br /> 'Y . <br /> ERFOR ED! Toumshlp <br /> Ran!)e 5ectlon <br /> PEW <br /> TO BEp <br /> PEW WELL I BORING(OFT,GEOPR08E,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 4ZOIL 90RING# _ N DESTRUCTION(choose <br /> type Uher: <br /> 11 WELL 0 0 OVER•BO Below) <br /> DMMEN7S; Grout Speaflcatlons: D PRESSURE GROUT <br /> �c IN5TALt 41LQN I 2jQAjP <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOL k <br /> X1'RACTION D AIR HAMMER/DRIVEN CASING THICKNE��MUL71PLE CA$INGS7 p YES � WELL CASING pJA�, <br /> /APOR D MUD ROTARY TYPE OF CASING: 0 STEEL U PVC [I OTHER; --�- <br /> UR SPARGE DEPTH OF GROUT SEAL Z �_TREMA:7YPg TO BE USED: C AUGER$ <br /> D PUSH POINT GROUT SEAL PUMPED: 0 Yes D HOSE <br /> COIL BORING D HAND AUGER tto (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> )THP-R: y���Ea � ���� GROUT SPECIFICATIONS: rn�� -T <br /> -'� , - APPROX.BORING DEPTH� Z.o <br /> CONDUCTOR CAST PROPOSED? 0 BOLTED TRAFFIC BOX or 0 STQVE PIPE <br /> )MMIaNTS: 1 p li r. it <br /> �`.-5 $ ( xe®.IIsi Specifications here): <br /> OA <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 40-W-ORjQNC;HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> <arQby certlfy that I have Draper®d this application and that the work will be done In accordance with San Joaquin <br /> unt dinartces,iRuies and 119gulattonc,and all applicable California State Laws. <br /> led ) ,_� q <br /> IN <br /> Title/Company <br /> e ~Jo n 4rJ <br /> DEPARTMENT USE ONLY Det <br /> E MAP IN UNIT IV FILE,ADDR SS: <br /> IRK PLAN DATED: L �� L <br /> loation AooeptLSy <br /> R Inspection t3t� Date Iasued <br /> ruction In: cDate Final Inspection By �— <br /> t7ate <br /> IMENTS/CONDITION5• ------ , <br /> e r ra G:L <br /> DOUNTING ONLY. AID# <br /> CODES FEE(NFO AMOUNT REMITTEDcar <br /> CHgCK# REC'D E3Y DATE" PEkmrf/SERVICE R@QULVOT 6 INVOICE <br /> 7 WC___-WAEV>_ <br /> "'-- �_ C-57 Letter of Authorization to signermft Oc. <br /> P Encroachment doc_ 1/25/02 <br />