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I10/11/2062 16 13 20946830-1 FIFTH FLOCR PAGE 02 <br /> WELL PERMIT APPLICATION FORM0 SATE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL, HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton;,, CA", 95202 �-- <br /> (209) 468-3449 <br /> I NON-REFUNDABLIE PU MMTT EXCPIRES 7 OM SUED <br /> DATE IS <br /> Applle abort i5 he-rely made to San JoaqulYi Courtly fer a pemvt to Construct and/or Insall the work desc abed This application is made in oompllamm vall San <br /> Joaquin County 0eveiopment Title.Chapter 9-1115.3 and the Standards of Sari Joaquin County Environmental Health ADepartmnil <br /> 9 <br /> WELL Location 0i ia� iL r'Fue AssessorJs <br /> cul sbrel �� �c,t}r SnL K x-or1 Z[p 9� i <br /> PROPERTY iV6 N ti Pr, Foo or IRI P-, <br /> D�iL�,�} ATa r Address f' . <br /> n� City >fT�I ?-rp gSZo� Phoned <br /> C- <br /> 7 Cantractor ` Rddr � �>'/L]g RAnxP+t rs <br /> hA tr Z ! � atY� �a �ip9S 7Y�-Llts�7►7�to <br /> CArlSultant/Sub Cntr i�r ivC2 ' IWdr�,.S U 3 .�f�+Qu1 !S�C.I J"T9[�(� <br /> b ^"1 LI1.��_Phone# 4 !a0 b <br /> GIS Coordinates X Y , .' Townshrp Rani e 8 5el <br /> WORK TO BE PERFDRMF33 <br /> NE;V4/WELL!BORING(CPT, GECPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 0$OIL 13ORING# II DESTRUCTION(a4le type below) <br />' �SVELLS _ !OVER-BOIL <br /> "(Xhl PRESSURE GROUT <br /> COMMENTSGrout Spieafications <br />' i E OF WEL1- INSTALLATION TYPE CONSIRYCTI N SPECIFICAI'tONS <br /> 1QNPrpR1NG �i OLLg STEM DIA OF:BOFtE}i>�LE 4 i_ MULTIPLE EASINGS1,WMULTI-LEVEL?9 WCLL CASING D! <br /> j11 EXTP 1CTION p AIR HAMMERMRIVEN CASING THICKNESS t�v�2 A` <br /> TYPE OF CASING Q STEEL Q PVCOTt'ER -I r nom! <br />' djjKAPOR Q MUD ROTARY DEPTH OF GROUT 5 e— TREMIE TYPE TO$C USED All <br /> R 6F'ARG> Cszane Q PUSH!}OaNr GROUT SEAL Pll '(Yes [I No (NOTE MAXIMUM FREE-PALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS �r <br />' 13O7'HI=R..,-,._,,.-1f 4TNBR__ ~ � �` 501:" v�et1 P afl ��_� APPROX.BORING DEPTH urn MOLTED TRAFFIC 13OX or Q STOVE PIPE <br /> 'COMMENTSCONDUCTOR CASING PROPOSED?_6 a Cif 1(E3.list sparCitiCatiCrls here) <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 certify that I have prepared this application and that the work will be dune in accordance with San Joaquin <br /> County Ordinances, Rule$and regulations,and all applicable Callfarnlaestate LAWS. <br /> Signed x Trtleicampany <br />' -'rtnt Na7k3 <br /> Ozn <br /> DEPARTMENT USE ONI~Y wtq-�- Jr f <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> NORK PLAN DATED- <br /> Opficatien Aempted' 8y - v Date I=uednspectlon t3y <br /> C.(/'rout lnspecdon BY. Data Final i <br /> Date <br /> estrul Insper�oR By Date — ----� <br />' RtVtlVIEFrTS/GON[D17tpNS <br /> UN'I ING ONLY AID# <br />'7Pr-OQES F15E WFO� AMOUNT REMInTTED Cl IS K V I;1l BY DA E POWIT f SERVICE REQUEST iNVOICE <br /> 0: • r S--Sct <br /> -57 WC -WAxVER C-57 Letter-of Authorization to sign permit_ _Encroachment doc_. 8/29/02 <br />