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%35/17/2001 13:35 2U0ObUJ43J rIr tn r�_2.r. — <br /> 2 WELboPERMIT APPLICATION F07<M SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> M <br /> MAY 1 8EMORONMENTAL HEALTH DIVISION (PHS-EHO) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 9520.2 <br /> ENVI iNMENT HEALTH (209) 466.3449 <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construot and/or Install Me vmrk Cesenbed. This application is made in wmpllanw lith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Pvboc Health Services,Environmental Health Division. <br /> r� Assessor's <br /> WELL Location12(Q$(n Locke,- FSC10kA��iS�Cross Stree; N �, , la r�city�zip95a37 ParceI 65j".3�0—O.Z�� <br /> PROPERTY Owrl91QrAtldtess 190%(a I QC,�CQ 151}}1._Ci;�tyLL kQ,�Zipg52 Phore#jC)q- 7ol7- 3130 <br /> :-57 Contractor 1 ddre55�(D3a t.Jt\1(7,[I �1rCii>C`�Mtloch2iC#�Lj� ((yQ <br /> p 1 hone#�l`f(P-lD3g-I <br /> '.onsuhan:I Svt Contractor 4 Address•(,Igq S.RlA`Q City Uc# Phone#_j,1(o- 1.-33R► <br /> ;f3 Coordinates:X Y, Township 411 Range 79 Section 3(D <br /> YORK TO BE PERFORMED: <br /> I NEW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER;OTHER`) D DESTRUCTION(choose typo below) <br /> D SOIL BORING# DOVER-BORE <br /> WELL# O PRESSURE GROUT <br /> Other: GROUT SPECIFICATION <br /> :OMMEN'f5: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �MONFORING HOLLOW STEM DIA.OF BOREHOLE IOU MULTIPLE CASINGS?0 YES NO WEIL CASING DIA: <br /> I EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS SCL4 re0 TYPEOFCASING: BSTEEL (PVC []OTHER, <br /> i VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 70' TREMIE TYPE TO BE USED: D AUGERS OHOSE <br /> AiR SPARGE 11 PUSH POINT GROUT SEAL PUMPED: ) Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATION <br /> OTFIER.: ,_D OTHER APPROX.BORING DEPTH /20r BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? d O (if YES,list specifications here): <br /> OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty O4THEIT <br /> ws, and Rules and Regulations of San Joaquin County. <br /> CSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 9nedx TIUe/Company Q=,AVM',I mQ(l(1Q r AAcn(10 1 CII Ino IT)(% <br /> 'int Name Date 5-17 -L71 <br /> ITE MADDRESS: <br /> JORK PLAN DATED; _ U12W t;o O 200jjAjA'r <br /> DEPARTMENT USE ONLY f�/p <br /> wtwtion Accepted By. Date issued 4 Area <br /> Oat, f <br /> 'out Inspection By Date -� D Final Inspection By Date t <br /> tstvcUon Inspection By Date <br /> 3MMENTSr CONDITIONS: 12, <br /> iCCOUNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK# I RECO BV DATE IF PERMIT f SERVICE REQUEST# INVOICE <br /> 2�oi <br /> 57` WC_-WAIVER,__ C-57 Letter of Authorization to Sign pernir_- Encroachment doc_ 9/12/00 <br />