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11/01/2000 13: 04 209468343: FIFTH FLOOR PAGE 04 <br /> • <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E, Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> caquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> /gyAssessor's <br /> VELI-Location JI6GG Lt_ (L�t.:rd �2- p_Cross Street city_j&6: Zlp Parcel# <br /> 'ROPERTY Owner u 7 Ll� Address s ,J Ci Zip Phone# <br /> eL UYr o.s u7a-m ` city­ <br /> ;-67Li S 2.2 one# <br /> Contractor AddressIr,I <br /> //'' i'7o t ' rtcf(�EL��A ry ,t yiodA Lic# Phone# �/6 ' 7'�'er l3 <br /> ;onsultantl Sub Contractor—g"", A,-�, isL7,&6 I. ddress <br /> 31S Coordinates:X, .Y ,Township Range Section <br /> NORK TO BE PERFORMED: <br /> NEW WELL I BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 <br /> DESTRUCTION(choose type below) <br /> SOIL BORING# I H�%'�jk < p OVERBORE <br /> W ELL# I?H n '3 [(PRESSURE GROUT'Other. Grout Specifications: <br /> ------------ <br /> COMMENTS: S <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCT'ON <br /> SPECIFICATIONS i.1CI�LS ' <br /> MONITORING 1i HOLLOW STEM DIA.OF BOREHOLE 6+t MULTIPLE CASINGS?RYES NO WELLCASING DIA: Z <br /> R EXTRACTION BAIRHAMMER/DRIVEN CASING THICKNESS ScN. 40_TYPEOFCASING: OSTEEL jjPVC BOTHER: <br /> R VAPOR B MUD ROTARY DEPTH OF GROUT SEAL Z- TREMIE TYPE TO BE USED: 'Ili AUGERS B HOSE <br /> BAIR SPARGE n PUSH POINT GROUT SEAL PUMPED: R YesNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> R SOIL BORING aRAND AU GER GROUTSPECIFICATIONS; �!61T C&V`CN ` <br /> R OTHER: U OTHER APPROX.BORING DEPTH '1-C #BOLTED TRAFFIC BOX or -0 STOVE PI -W) <br /> CONDUCTOR CASING PROPOSED? C'S (if YES,list specifications here): ON5 (+E.l-f- . <br /> 'COMMENTS: C r- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O dinances, Rules and Regulations, and <br /> �all <br /> '1applicable` <br /> ' aliforriaa 8 teal ft&L a n/A 7°^) <br /> Ivl�rylp✓"t TW/C'o... <br /> Signed x ._ Yn <br /> Print Name � �to �) -LV n 1 1 6 A� , - -- 1. Date C Ca <br /> DEPARTMENT USE ONLY [ � , CAi-ic,r�) <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: 1k - 0 - C) -C) <br /> Application Accepted Date Issued 2-( Area <br /> Grout Inspection By <br /> () Date Final Inspection Sy Date/y 0 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNT REM] CHECK# RECD BY DATE PERMIT]SERVICE REQUEST# INVOICE <br /> ;)Aol is-lei 15 <br /> C-57! WC ^-WAIVERC-57 Letter of Authorization to sign permit—Encroachment doc_ 9/27/00 <br />