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02/1912002 16:12 209468343 FIFTH FLOOR <br /> 0R ANAL. <br /> WELL PERMIT APPLICAT ON FORM SITE <br /> SAN JOAQUIN COUN1 Y MITIGATION <br /> ENVIRONMENTAL HEALTH DEP TMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> )plication is hereby made to San Joaquin County for a permit to construct and/or instail the wo ic described. This application is made in compliance wllh San <br /> Paquin County Development'rItle,Chapter 3-1116-3 and the Standards of San Joa vin Count, %vironmental Health Departrnent <br /> 'ELL Location S Cross Street in j I� Assessaes <br /> h' 77,706et I Zip Parcel# <br /> ROPERTY Owner/ Address W City Zp S9 aG�spPhone# e9- 9!/!-_7873 <br /> -57 Contractor eW6t it & Address Z .i City p�-U T( Phone# /4,63 7Z <br /> onsutiant!Sub Contractor� i�1~L1/uG address r City ra (bfcik Phone# ql�- 22�-33b0 <br /> z <br />:IS Coordinates:X ,Y "Township. Range Section <br /> IORK TO BE PERFORMED: i <br />"EW WELL 1 BORING(CPT,G OPROBE,HYDROPUNC�}►HAND-AUGER,OTHER*) 13 DESTRUCTION(choose type below) <br /> g'S�OIL BORING# j]OVER-BORE <br /> Q <br /> WELL# a PRESSURE GROUT <br /> Dither: Grout Specific)' ns: <br />;OMMENTS: <br /> YPE OF WE[.L STALLATIOIV TYP CONSTRUCTION SPE ICATIONS <br /> I MONITORING OLLOW STEM DIA OF BOREHOLE -MULT LE CASINGS?I]YES OQ WELL CASING DIA: <br /> I EXTRACTION MER/DRIVEN CASING THICKNESS E OF CASING: 0 STEEL []OTHER: <br /> I VAPOR p MUD ROTARY DEPTH pF GROUT SEAL a TREmirz TYPE TO BE USED: aAUGERS is HOSE <br />=SP GROUT SEAL PUMPED: a Yes n N (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'} <br /> NG []HAND AUGER GROUT SPECIFICATIONS:APPROX.BORING DEPTH jgjjM +U n BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? {If YES.Ilst specifications herek <br /> COMMENTS: i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS op. ENCROACHMENT PERMITS. ' <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVAN E FOR ALL REQUIRED INSPECTIONS. <br /> i' <br /> hereby certify that I have prepared this application and that the work w II'be done in accordance with San Joaquin <br />:ounty Ordinances, Rules and Regulations, and all applicable California.State Laws. <br /> igned Title/Company T d <br /> tint Name <br /> Date_ <br /> DEPARTMENT USE ON Y <br />;ITE MAP IN UNIT IV FILE,ADDRESS: ZCC5 � U,((.',. <br /> YORK PLAN DATED: ..�- 6 — O 7- <br /> PPlieation Accepted By. Date Issuedrz .0 Vea <br /> rout Inspection IBM Date Final Ins coon By ate <br /> estruction Inspection By Date <br /> OMMENTS l CONDITIONS: <br /> ACCOUNTING ONLY: Alt]# <br /> PE CODES FEEINFO AMOUNT REMITTED # WD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 1!21 <br /> sRi 00 I 113 <br />'-57 V WC -WAIVER C-57 Letter of Authorization to sign p rmit V Encroachment doc.,� 1/25/02 <br />