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11/13/2003 16 23 2094663433 FIFTH FLOUR PAGE 02 <br /> WELL. PERMIT APPLICATION FORM SITE <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDASt.E PERMfr EXPIRES 1 YEAR FROM PATE ISSUED <br /> vltmhon is hereby made to San Joaquin County for a permit to construct and/or Install the worts described This application is made in compliance with San <br /> 4iquin County Oevelopme ft Eanberg-1111lrLJ and Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> a Assessor's <br /> ELL Locatlo � n ss Sts t - City Sty k.K ,l 21p Parcel# <br /> 1OPERTYO4vner Address /� C,ty Imo— Zip Phone# <br /> sr Contractor Addre&5p1'F C. -zipLlc# o Phone#!'71 �yy <br /> Dnsultant/Sub Contractor Addr�es5 City Lico Phone#C. - op <br /> � g52�'a <br /> IS Coordinates X 'y Township Range Secuort <br /> ORK TO BE PERFORMED <br /> NEW WELL f 60RIHG(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION(choose tyle below) { <br /> -W(],SO1t_BORIN # 0 OVER-SORE <br /> ELL# -^ a PRESSURE GROUT <br />)cher Grout Specitications <br /> OMMENTS <br /> E OF WELl, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Ct•J h W uLe,} <br /> It <br /> MONITORING Q HOLLOW STEM DL4 OF BOREHOLE MULTIPLE CASINGS?0 YESNO WELL CASING DIA W �_� <br /> ONI )(AIR HAMMERIDRiVEN CASING THICKNESS TYPE QF CASING 1]S EL XPVC Q OTHER <br /> Q MUD ROTARY DEPTH OF GROUT SF11L l l !i'�"'rl�c]REMIE TYPE TO BE USED a AUGERS Q HOSE C <br /> AIR SPARGE Il PUSH POINT GROUT SI=AAL PUMPED YYes a No ijNOTE: MAXIMUM FREE-FALL DEPTH IS 30') C <br /> SOIL BORING Q WAND AUGER GROUT SPECIFICATION fi { <br /> OTHER _ fl OTH€R APPROX BORING DEPTF OLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPIOS D? {if YES,list speeif+eaLons here) I <br /> a�aMEI�Ts• a 1wal 002& 12 <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 /> hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations,and all applicable California State Laws <br /> Qnedx Title/Company 7 $ II,�, �1�Y <br /> int Name Date W <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br />►ORI(PLAN DATED: <br /> 011=rmn Accepted By 1JkAA-41-U _Date issued ! U Area <br /> put Inspection 6y Date Flnal Inspection By Date <br /> aftuction hopeobon By Date <br /> Y I CONDITIO s- <br /> U=UNTING ONLY AID# cA <br /> 9 CODES I VEE INFO AMOUNTREMITiED CHECK* RECD BY DATE PERMITI SERVICE REQUESTS INVOICE <br /> SRO d -D .3 6 <br /> 671— WC -WAIVER C-57 Letter of Authorization to sign permlt Encr'ooehment dos 9/27/00 <br />