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12/07/2000 09:52 20946834?1 FIFTH FLOOR _ PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> d DAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (249) 468-3449 <br /> NON-REFUNDABLE PERM Fr EXPIRES 1 YEAR FROM DATE VRD <br /> 7pilcation is hereby hr a tO Sart.loaquin County for a permit to ccnstruct and/or install the wdrk deSCdbed. This application is made In Compliance�,J�th San <br /> :aquin County DevetopMent Title,Chapter g-1115.3 and the Standards a Sat+Joaquin ounty Public Health Se t,Environmental Health Divislor <br /> _ Assessor' <br /> !=LL Location Cross S refit J City p ParGelfr ZO"7'T <br /> V r G Address 4^ tNCN Qsry '. �p Phone# - �5 <br /> ROPEFtTY Owner 4_ <br /> 57ConGactor 1r8�, c-rc ddrsss�Q ,'��fr C4. , ,, Zip C/ C:G Sp,11,�Ph8nef� <br /> ortsulbnt!Sun Contractor JN �-l.0 Adore ^ �'1 Clry , _LicPtiane7° <br /> ;I5 Coordinates:X Y Township Range Section - __--- _ <br /> JORK TO SE PERFORTUIEQ_ D RUCTION(Ct5o05e type bstow) <br /> `NEN+WELL!BORING(CPT.GEOPA089.HYDROPUNCH,HAND-AUGER. Q p OVER-BORE <br /> 11 SOIL SORING# �I p PRESSURE GROUT <br /> other: Grout S c ftadonz: <br /> :OMN ENTS: <br /> 'YPE OF WELL INSTALI-ATION TYPE CONSTRUCTION SPECIFICATIOM 11 <br /> YIVONITORfNG `HOLLOW STEM DIA.OF BOREHOLE _ MULTIPLE CASINGS?AYES ❑NO WEt..L CASING DIA: . <br /> I FRACTION '1]AIR HAMMERIORIVEiN CASING TH1CKNEW 0.02-! TYPE OF CASING: 13 STEEL )(PVC ©OTWEi� <br /> ]VAPOR 13 MUD ROTARY DEPTR OF GROUT SEAL, 'I W _TREMIE TYPE TO BE USED: �AUGF-RS []HOSE <br /> ]AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: xYes a No (hl TE- IVIAXIMUM FREE-PALL DEPTH IS 30') <br /> j SOIL BORING HAND AUGER GROUT SFECIFICATION T � er- �t� W � � <br /> OTHER: _11 OTHER APPAOX.BORING pEPTH I�eLD BOLTED TRAFFIC ons re U stOVa PIPE <br /> CONDUCTOR CASING PROPOSED?�(if YEB,list spaaYlCalions here}:. <br /> 'COMPnENTS <br /> NOTE; OFFSfTE 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 J1020in <br /> ;ounty Ordinances,Rules and Regulations,and ali applicable califamia State Laws. <br /> Signed elZ Lar' Tr�•t Le-, <br /> Dat- d 5 t) <br /> Print Name S[ 0�F-P A R�TM E�NT USE 0Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS! <br /> WORK PLAN DATED: - <br /> 1, T; Defe Issued <br /> Appticstior�Accepted l3Y y <br /> to Final Inspection 8y <br /> Grout lnspec5on 8y r <br /> Destruction Inspection By Date <br /> f <br /> COMMENTS/CONDITIONS: <br /> ACCOI,INTING ONLY: Aid# <br /> PE CODES FEE INFO AMOUNT REh11TrED CHECK# RECTI BY DATE PERMIT <br /> t 3EH1L1GE REQUEST1111 INVOICE <br /> 24 <br /> 3 6*01 SSG �e &DI 2 <br /> C-57— WC -WAIVER C-57 Letter of Auth - on/I"p`6ign Permit £ncrccchment doc 9/27/00 <br /> FEB $ c iC11 <br />