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02/13/2001 08:36 2094683433 FIFTH FLOOR PAGE 02 <br /> I <br /> WELL PERMIT APPLICATION FORM . SITE <br /> MITIGATION <br /> /5:11> SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)460.3449 ! <br /> NON-REFUN20LE EERMIT EXPIRES 4 YEAR FRO 9ATE 19MR <br /> I 'pplication Is hereby made to Son Joaquin County for a permit to 00neiruct arWor install the work desufbed. This oppilcown Is mode In a rnolonee with San <br /> mquin County Development Tltle.,Chapter 9-11115.3 and the Standards of San Joaquin County Public Health Services.Environmental health Division. <br /> 4pr eneAs Assessor's <br /> 'iYE6L Location �. >• a [lC►oaS Streetil; ^r fivfty c, ..zip . Parcel# <br /> ROPE RIY Owner Address L�1 `�VJQI1 _ City. r Zip_ Cf S Z Phone#_ <br /> 19-S7 Contractor ICR c i i• ddress ��iJ_ �r I _City p �5'ie.lel Pham#_ i 3 �`� <br /> —eosuttxntr$ubCorrtractor C142N 1-lilt_ Address � ' vim. CIty�Q}CIt Lic# Phone# Q_z5i 2F <br /> 2;01 <br /> ,I$Coordinates: ,Y ,Township RBrlgetforti _ __ <br /> EW WEI0 BORING GP ROPROSE,HYDROPUNCH,HAND-AUGM OTHER*) Q DESTRUCTION(dmov type below) <br /> f SOIL BORINGS {i OVER-BORE <br /> 0 PAJiSSURE GROUT <br /> "Outer. Grout Specmcatlon5: <br /> I. ;OMMENTS: <br /> I <br /> Of IHSTAt.IATION TYPE o s' U IF 6 PIONS <br /> q MONITORING LI HOLt-OW STEM DIA.OF BOFtEHOt E _ MULTIPLE CASINGS?[]YES []NO WELL CASINO DIA: <br /> " [EXTRACTION GAIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: q STI"EL Q PVC p OTHER: <br /> il A VAPOR a MUD ROTARY DEPTH OF OROUT SEAL TREMIE TYPE TO BE USED: it AUGEFkS a HOSE <br /> QAIRSPARGE p PUSH POINT GROUT SEAL PUMPED; Ves. a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') . <br /> I.UORING 13 HAND AUGER GROUT SPECIFICATIONS, <br /> _1 v r1tIER• •OTHER CrT APPROX.BORING DEPTH- I _ Q 60LTEO TRAFFIC BOX or to STOVE PIPE <br /> CONDUCTOR CASINO PROPOSED? 1 _(If YES,list specifications here): <br /> "COMMENTS; <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 qertlknf that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County rnVes,Rules an Reg ns,and all applicable California St a Laws. <br /> 31Ened '0tterCompany. <br /> Print Name. <br /> DEPARTMENT USE ONhY <br /> SITE MAP IN UNIT IV FILE,.ADDRESS: M <br /> WORK PLAN DATED'' I zs �D o <br /> appltcmHoe�Aat:epted By S`-rfZcv`^ _Date Issued 3 n I Aral <br /> Grout Inspectlon I3y Data Final Inspeection By Date <br /> Destr'uaogn Inspection Date _ <br /> coMMHNTB i CotV[moms: <br /> ACCOUNTING ONLY: AID# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# RECM 8Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ITT <br /> C-37 WC -WAIVER_, C-57 Letter 6f Authorization to sign permit—Encroachment doc_ 9/27/00 <br />