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98/14/2002 16 18 2094683433 FIFTH FLOOR PACE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> I . SAN JOAOUIN COUNTY IVI ITI GATI O NUNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-L21:FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ilication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applreatlon is made in compliance with San <br /> aquin County Development Title,Chapter 9.1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> 44 Assessar'9 <br /> LI-Location 3 SQ s• �� � A��Cross Street City .,.Trp Parcel3F aSOT9 <br /> OPERTY Owner QAC rF�c _ A ri d s SPIeF Sox �.?S2 city J1'A&S4,r*M0 Zip Phan# xZ 5 <br /> 4,9 <br /> Contractor 10=4 i wE5 T P!a a G 7 7 �tE 8� yup •23S17 e# 90 ASB•0200 <br /> 1"'uKant I Sub Contractor Addres City Lrc# Phone# <br /> O <br /> � / o <br /> Coordinates X l -17_ �.00 w A& A .� Township_ Range SeG1on <br /> 0&44e 44 S,p.�+ �4P s <br /> IRK TO BE PERFORMED <br /> NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 1]OVER-BORE <br /> Il WELL# 1]PRESSURE GROUT <br /> hor Grout Specifications + 3D'iso lia <br /> MMENTS 68 <br /> S OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIO 5 r� 40 <br /> ONITORING U HOLLOW STEM DIA OF BOREHOLE �MULTIPLE CASINGS'd YES ONO WELLCASING DIA�'50' <br /> EXTRACTION )41R HAMMERJDRIVEN CASING THICKNESS TYPE OF CASING []STEEL XPVC []OTHER <br /> AP R //0 MUD ROTARY DEPTH OF GROUT SEAL �' F TREMIE TYPE TO BE USED [IAUGERS HOSE <br /> 1 RGE Q PUSH POINT GROUT SEAL PUMPED Nes ONO (NOTE: WUM FREE-FALL DEPTH 1S 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS en f Solid <br /> rMMIENTS <br /> ER UOTHER APPROX BORING DEPTHZjQf�X8OLTED TRAFFIC BOX or I]STOVEPIPE <br /> �JI�gIR0G[k mF rlov"e CONDUCTOR CASING PROPOSE017 {if YES,list specIficatlons here) <br /> 5 W/ <br /> eo N7-o4".,Pw-47PP o mss' jewerogirwiz ra •84e <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 /> lunty <br /> ereby ce I have prepared thisapplication and that the work will be done In accordance With San Joaquin <br /> na ces I s a a ns, and all applicable California State Laws. <br /> nd i leefcompany Gide/zpN wrg4 .54 C ffi'< <br /> jnteNaxme�­ 0zFA-"-r Lb i��Ya An" Date <br /> DEPARTMENT USE ONLY <br /> E MAP IN UNIT IV FILE, ADDRESS' <br /> ORK PLAN DATED' t'�!// <br />[plication Accepted 8y �l '' Date Issued A L4 I r F Area <br /> ut InspecUon By Date Final Inspection By Date <br /> estruclran Inspection By Date <br /> MMENTS I CONDITIONSa_ ba4fTele h ,/�7 Let <br /> �' <br /> A NTING ONLY AID# 1� E12 <br /> `5 G win ve S O -e r ar O7��f�Q <br /> >rar <br /> E CODES FEE INFO AMOUNT REMITTEb CHECK F REC'D BY DATE PERMfT/SERVICE REQUEST# INVOICE <br /> �rDr g f. 0v -3� 2 VI OZ 15 RAE 3 O <br />�57 WC--WAIVER— C-57 Letter of Authorizatrn slin permit Encroachment dmc i125/o2 <br />