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WEL PERMIT APPLICATION FIRM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS•EHD) UNIT IV <br /> `- 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> HON-amNQABLE PM ru—P!m I ee s l ere as.lFe, <br /> main IIeunty Development� So gJaaguln Caunly for a Peon*to mnebuet andlgr vwtall the xxxx dasalbed. This applic4Non is made In cmVr Dc*"Ih San <br /> Ch9-111 a2 and Ina standards of San Joaquin CoUlty Public HoWlh Sen4xs,Envromlrr"Health Dlvlabll. <br /> IIELLILD"tion x1606 EI R4ncLO Ed. C:MsaSbwt Gly TAAc� 210 paw OYs <br /> 'ROPERTV Owner Rleha rd Ab Above. 04.:F Acy <br /> �T�_Zip Ptwne# <br /> C-VCantmcbar?rOujoM SAMFI;n —Add"Q±1 092UTH 50 ${, Cft lchmond71p��„IdF63638� P 0510 a3�- 4575 <br /> Censleeantlsubcmw�da�rown and CAL0k4et- Addrm G13 VVou KAauArl City IRVIN ucte PnaIrs0�9H9)abv-blSb <br /> GIS OoaMinatea:X .Y..TwmaMp Range sodon <br /> E <br /> aW WELL/BORING(CPP'T, OPROB HYDROPUNCH,HAND-AUGER.OTH9Lh n MFrRUCTION(0==Wo bm v) <br /> �801LBORWGN TOTAL of S aOVFA-EOM <br /> 0 W ELL# <br /> '�� Grout Sper95catlorrs: 0 PRESSORS GROUT <br /> COMMENTS ToTA o S (yeoPm e. Robe hoL.t9 -kn - below foJe- and colics round.wc"}er tam�tt <br /> and bat ,ll w Cemen+ bent. <br /> TYPE OF WELL )NypTALlATION TYPE 06N�UCTION SPE (P—X_eTIONN3 9CC)U{ <br /> 0 m0wroRWG G HOLLOW STEM DA OF BOREHOLE MULTIPLE CASINGS?p YES ONO WELL CASING pl/A <br /> 0fixr ACTION UAIRHAMMERCRIVEN CASING THICIg4= �TYPEOFCASING; USTM 0PVC OpTHER� <br /> p VAPOR U MUD ROTARY OEPTH OF GROUT SEAL .TREMIE TYPE To BE USED: 0 AUGERS p Nos£ <br /> OAIRSPARGE [)PUSH POINT GROUT SEAL PUMPED: 13Yes 11No (NOTE: MAXIMUMFREE-FALLDEP MIS301 <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS; <br /> POTHER �OOTHElkAPPROXBORING DEPTH OBOLTED TRAFFIC 64OX or 0570VEPIPE <br /> 'COMMENTS: CONDUCTOR CASINO PROPOSED? (i(YES,fist 9p dSc2lions herr,)`_ <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 /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances,Rules and R4gulations,and all appGeahta California Slate Laws. <br /> SldnedX� A5 AGEniT F00. N�NIER G.ICETI�µD ubwn $o,,.pl�,.ol <br /> TIdeIColrlparry_ $rOwn1 S;.Print Name NO.dtn2 �,-C(Zpu 0 -- 31z� of <br /> DE�ARYMENT 'UnSE ONLY <br /> SrrE MAP IN UNIT IV FILE,ADDRESS, O O l o Q VC crM , r n <br /> WORK PLAN DATED: �L 1 3 Irl I/A I <br /> Application Acespted Br i DdtL:,w 3 `l D I A„� ti' <br /> Grout ImpactionB3' oatd Foal Inspe wn By-m DMIQ3=5 <br /> DesUuctlen�etlon Rt Date <br /> COMMgNTSICONCRKmNS= <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTEO CHECK# RECD BY DATE PERMIT)SERVICE REQUMO INVME <br /> a'� B z 7 3 a / VSs S?1 <br /> C-57_ Wt-WAIVER-- C-57 Letter of Authorization to sign permit__-_EherogchmenY dot— 4/27/0 <br />