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09/28/2001 12 13�`� e2094683433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> - -- MfTIGATION <br /> F,---'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> SLI' 2 G 2001 304 E. Weber, Third Floor, Stockton, CA., 95202(209) 468-34496951tvb <br /> Yi;:�;f'�;�J� ti5 i��a NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED isle wsit�San <br /> Appl�ratron is hereby made to Sian Jflagwn County for a permit to cartstrud anvor Install the work described This applrratron is made in camp <br /> Joaquin County Development Title.Chapter 9-1115 3 and the Standacds of San Joaquin County Public He/a��th Services,Emironmental Health D%A ion <br /> WELL Location 3 6 �' •4 �r,-e Cross Streit 1� Citty S-441e'''I`I _rip �� Parc# <br /> PROPERTY Owner C` G 7''7 7��47c... Addr o f +city S'f `lT�'• Tip Phone 2a? <br /> IV city? <br /> C 5r Contractorl,G � /�� _address RG• X36 : /4' ' �. 7,pV` $7l uot� l �Phones 7 41 Vc` <br /> Consuttantl�tar G!✓n � -LC . Address /�� �� ctty_�ic#5�3�•57 Phone# S 6425 25 <br /> GIs coordinates Y Township ..2 A _ --Rar9e Section 2 <br /> WORK TO BE PERFORM ED ! v'bESTRUCTION(choose type below) <br /> ON WWELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HANt}AUGER,OTHER") I ('"�_ VbVER-BORE <br /> Q SOIL BORING# RESSURE GROUT <br /> SWELL# I?IGt�s f Yyr Grout SpecrFcations I'r}G Herm 1 SYa n- l.'t- <br /> 'Other: <br /> COMMENTS GvS Zml J .rjaet floc." ce�cc�2? ,?E-v-- t ke <br /> TYPE_ OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING 13 HOLLOW STEM DIA.OF 80REHOLE_� <br /> MULTIPLE CASINGS?0 YES p NO WELL.CASING DLk <br /> RACTION Q AIR HAMMERIDRIVEN CASING THICKNESS_„^,.TYPE OF CASING D STEEL ©PVC D OTHER <br /> OR g MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED D AUGERS D HOSE <br /> JIMAPD AIR SPARGE D PUSH POINT GROUT SEAL PUMPED D Yes p No {NOTE MAXIMUM FREE-FALL DEPTH IS 30'} <br /> q SOIL BORING 17 HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or 13 STOVE PIPE <br /> a OTHER J3 OTHER APPROX BORING DEPTH_ � ! <br /> CONDUCTOR CASING PROPOSED? (r YES,list speccztrons here) <br /> 'COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENC OACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANGE FORIALL REQUIRED INSPECTIONS <br /> I hereby certity that I have prepared this application and that the work will be dome in accordance with San Joaquin <br /> County Ordlna s, Wes and Regulations,and all applicable California State Lbws ` , / <br /> TrtserC«„pam� <br /> Sgnedx <br /> Print N � I?ate <br /> DEPARTMENT USE ONLY <br /> SrrE MAP IN UNIT N FILE,ADDRESS: 2'� A). <br /> ! <br /> WORK PLAN DATED: _p <br /> Applrcebon Accepted By <br /> ,Date Issued [ ?�7 � Are. <br /> Grout Inspection I3ony _Date Fina!Inspection By <br /> DestructiIns on By isDate <br /> MENTS 1 CONDITIONS: <br /> LACCOVINITING ONLY AID# f <br /> ES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE h ! s=RM}T t SERVICE REQUEST ii INVOICE <br /> r-R7 11 r _WATV;:D f_K7 I vttor of A,1thnriTntinn to a&nn nor ml+ l=nrrnnrh�r+ont r{nt <br /> a/77/Clfl <br />