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01./•.l_912A01 16:05 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED <br /> ,plication is hereby made to San Joaquin County for a permlt to construct and/or install the work described. Thls application is made In compliance with San <br /> aquin County Development Title,Chapter 9.1115.3 and the Si ndards of San Joaouin County Public Health Services.Environmental Health Division. <br /> '/ h"1, 5-V Assessors <br /> ELL Location `/d'J „t.(.,�M //;w! q9 _croas street /�f wf a Clry SjDLKTON Zip �7l Parcel# <br /> 20PERTY Owner�-A.t�t��'[�/i�d �n +If]Lf3 Address 3 C L L.y City / N(_ZJp f5W5 Phone# <br /> . I.// Gry <br /> 57 Contractor WG % /ttTnfAr Address 2J2j T'rr2lnE.G7L/)City C( Lip 7j1UcfSSY�l7 Phone# 9/6 63g 'TLT( <br /> �{ t <br /> onsuttantrS �^^ter — Address 30R/G ' <br /> RELt1/./ Clh'rf`� Vc i Phone# �686/'OY� <br /> � <br /> IS Coordinates:X ,Y .Tovmshlp Z N Range �E Section <br /> t0R..TO BE PERFORMED: type <br /> NEW WELL!BORING(CP T,GEOPROBE,HYDROPUg� H., AN�A(3 GE$_OTHER') 0DESTRUCTIONO(OVER-BORE e1 l <br /> 'SOIL BORING# fff �Y/ PRESSURE GROUT <br /> a WELL# Grout Specifications: <br /> Other. <br /> :OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING OLLOW STEM DIA.OF BOREHOLE S0y MULTIPLE CASINGS? YES �O W ELL CAS <br /> {Q�-IS ING DIA: <br /> ] <br /> EXTRACTION ) AIR HAMMER/DRIVEN CASING THICKNESTYPE OF CASING: (]STEEL G PVC p OTHER: <br /> ]VAPOR o MUD ROTARY DEPTH OF GROUT SEAL f TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Il Yes ANN MAXIMUM FM <br /> E-FALL DEPTH IS 30') <br /> 1101SOIL BORING n HAND AUGER GROUT SPECIFICATIONS:,. �Ol, / 0 BOLTED TRAFFIC BOX of O �PIPE <br /> J OTHER: OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? ,/a (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 NSPECTIONS. <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, RdleS and egullaations,and all applicable California State Laws. �i <br /> �� ` TitatCompany <br /> Signed x G'/e� --r p <br /> vc�r<v� Gate <br /> print Name_ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ <br /> WORK PLAN DATED: <br /> Date Issued <br /> 6 Area <br /> Appllration Accepted BY <br /> Date <br /> LOO Final Inspection By <br /> _ <br /> Grout inspection BY pate <br /> pestiucCon inspection By <br /> cOMMENTSi CONDRIONS: <br /> ACCOUNTING ONLY: AID# <br /> CHECK# RECD BY DE PERMR 1 SERVICE REQUESTil INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED <br /> Q - ,C c) l � Z O� f9 6 <br /> 3 s c7 I 9/27i00 <br /> C-57_. WC—=WAIVER_ C-57 Letter of Authorization to Sign permit_ Encroachment 60c— <br />