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03/13/2001 16:21 2094683 FIFTH FLOOR 49 PAGE 02 <br /> [R[E� �, WEYIELL PERMIT APPLICATION FORM SITE <br /> gAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> LIN <br /> APR 1 8 200T ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) I I <br /> ENVIRONMENT HEALTR04 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468.3449 LF,-�:D) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 19 2001 <br /> Application is hereby made to San Joaquin County toe a permit to construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 1' Fp4o,A{ A:aessore <br /> WELL Location Cl S' RARLAO Cross Street L-100 city L M Zip 9$231 Parnel# IR'57-1 Doi <br /> FR8>mt% L AM <br /> PROPERTYOwner (rRAu1J t"suRJAr(JM1- Address dt SOt{ S' N+�RLAtJ cityF�PVA�21p lsD•TN Phone# Zo0.-g8Z-ItZ� <br /> S tbasT0- - <br /> C47Contractor�C:CKS'ylz��u O-V Address (�toy Stbk-t2o-;1 Nd City 6LU j VII qzq}3Lio# phoneA�'S`i"7--37.�Zr <br /> Consultant/Sub Contractor K,%VL-4 LOP-t-HAddress TA'�-Loxtt • C14%auf1Et,421 Uc# Phono# 005-00.9-4 <br /> q;l01 <br /> GIS Coordinates:X 'Y .Township Range Section <br /> WORN TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# 0 OVER-BORE <br /> DWELL# 'J.. L n , �PRsES'SUREGR-OUT <br /> "Other; Grout Specifications; � h-%V- <br /> COMMENTS: <br /> A a. .,ill <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS BSL cT.dwfv <br /> I10NITORING a HOLLOW STEM DIA.OF BOREHOLE 21 '_„MULTIPLE CASINGS YE 0 NO /CLI CASING DIA:-2." ,- l <br /> 0 EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: EEL - PD OTHER: <br /> n VAPOR ` MUD ROTARY DEPTH OF GROUT SEAL2MAY-125 TREMIE TYPE TO BE USED: 0 AUGERS '43310SE <br /> 0 AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED:AKYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> u SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: c 't .p�� 0 r brL�4 5'/a Ica-ta <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH 13 OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED7�,(if YES,list specifications here): <br /> -COMMENTS: wt t B <br /> 2 YV L .st It is .o lid, �rh-' s�raL ;� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROAC MENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules <br /> ,,and <br /> ,-Regulations, and all applicable California State Laws. <br /> Signed x W Vr�Jn"'� TilerCompany �e-• \tl-3S V. L;r �,I r�7,t�L RR l 't ALPS,uti <br /> Print Name (3 AMct¢i V V C>LA-L' Date 3-1`I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PIAN DATED: <br /> r�, <br /> Application Accepted By 4 Ou Dale Issued / s Area <br /> Grout Inspection By Dale Final Inspection B Date <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDRIONS; <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# C' Y DATE I PERMIT/SERVICE REQUEST• INVOICE <br /> 2 3 <br /> C-57_ Wt---WAIVER C-57 Letter of Auth i t si n p r —Encroachment doc_ 9/27/00 <br />