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05/30/2003 09: 49 209468' FIFTH FLOOR PAGE 01 <br /> 1 <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 /> t (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS b <br /> tion is hereby made to San Joaquin County for a pertnil to consW d andlor install the work desrnbed Thhs applicedon is made in compliance Health <br /> Division.wllh San <br /> Assessors <br /> n County r evelopmeto San Chapter County <br /> a-11 t f o and the Standards of San Joaquin County Public health Services./�En�ranmenral Health Divishon. <br /> nn ll Zlp -I�Parcel#�� <br /> Cross Street 1/Va ay <br /> J_Locativn ,.�0 O E�—� � <br /> �: City l' _ZP <br /> �PERTY Owner ry�/tl/� Y�4_Address G afoa/� <br /> 'Contractor fa �rllltd�Addres6g� tbVy'P IZci_c h 7,p �'�.3Uc#�'B Phonet(gZS G3'� AO <br /> S'Ir jl 3 U,#� Phone#(,Z`F u'33"7b13 <br /> �ultant1 Sub contractor V Ks C,,A' Qfct h. vi Address- - <br /> -' Range Saction�— <br /> Trrwnship� <br /> Coordinates:X_ —•Y1� _ <br /> DESTRUCTION(choose type below) <br /> YO BE PERFORMED: OTHER') - pdVER$ORE <br /> W W ELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, PRESSURE GROUT <br /> a SOIL BORING# p <br /> 'WELL# Grout Specifications: <br /> N <br /> MMENTS:DQ m f CA <br /> I ZED <br /> �E OF WELL NSTA ION T`!PN ON3 UCTIO PECIF #TIONS <br /> REHOLE MULTIPLE CASINGS?DYES 0 NO WELL CASING DIIA_ <br /> DIA.OF BO <br /> ONITORING d HOLLOW STEM TYPE OF CASING: a STEEL Il PVC O OTHER:- <br /> 2 <br /> THER: <br /> 2)RRACTION a AIR HAMMERIDRIVEN CASING THICKNESS <br /> EXTRACTION <br /> MUD ROTARY DIFTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> fAFOR <br /> R SPARGE 0 PUSH POINT <br /> GROUT SEAL PUMPED: Dyes p No (NOTE, MAXIMUM FREE•FALL DEPTH IS 30') <br /> 10I1.BORING 0 HAND AUGER GROUT SPECIFICATIONS: STOVE PIPE <br /> p 80LTED TRAFFIC BOX or a <br /> �1'F•IER: p OTHER^ APPROX. BORING DEPTH!— Ilsl specfi@lions here):�� <br /> CONDUCTOR CASING PROPOSED? (RYES, <br /> IJMMENTS: <br /> CESSR ENCROACHMENT PERMITS. <br /> NOTE: OFFSITE BORINGSas woRKINGRNOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> CALL THE UNIT N INSPECTOR <br /> ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> � rel3nty Ordinances, R'les and R2egul and all applicable California date Laws, � <br /> t+P (�I Ci Ti11e Compa ry 4 3 03 <br /> igned xDate <br /> 'nt Name �N �tA pEPA rRTMENT USE ONLY <br /> R MAP IN UNIT N FILE,ADDRESS: obi w <br /> IWO PLAN DATED: 2 <br /> ` wl � J` <br /> Date Issued Ja tea' <br /> �plintio cepted BY Date�� <br /> Daley--Final Inspection By <br /> rout Inspe on BY Date <br /> )estructlon Inspedlon By <br /> OMMEKTS I CONDRIONS: <br /> ACCOUNTING ONLY: AItr7t <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DTE PERMIT I S RVI�G REQUEST# INVOICE <br /> Encroachment doc__ 9/27/OC <br />