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09/21/20e1 11 40 2994683433 FIFTH FLOOR PAGE 91 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS HD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 9 202 <br /> (209) 468-3449 <br /> NON•REFUNDABQ PERMrr EXPIRQS 1 YEAR FROM DA l STIED <br /> Applic2hon is hereby made to San Joaquin Cowry for a permit to conatntct and/or install the work described as apphcattoi+as made in laance nth Sen <br /> .Joaquin County Development Tide Chapter 9-11'15 S and.the Standards of Sart.Joaquin County PublIG Heal Services EnwronmeRtal Health aitlr Diws�on <br /> � <br /> ^ M+9rKt-r s7. Assessors <br /> WELL L .7ocatlon w ris b+r1 Cross street w)lSnn �Cdy j z �P —Part�E# <br /> 7at)iTar% <br /> PROPERTY Owner D f9 n)114.L Address J01 S In!t30 0 WA t <br /> C+ty S om, c Zap q5Z a <br /> 1 r Phone# 06'� prarh X233r+2y+1c 12 s't-, g <br /> C-57 Contractor e /vv Ad ress u r � I� ' Cit fi>we+M� �, 57� Lac#�,45,5�11 pfiane�F <br /> AR <br /> Gnsultant I Sub Contractor n <br /> Addresses 7M _ _ c=ad �+"`i^ '"�'rtl �Phon <br /> EGIS Caatdinates X .Y ,Township i2ange mon <br /> WOPC TO BE PERFORMED <br /> ETN WELL/BORING(CPT,GEOPROSE HYDROPUNCH,HAND-At1GER,4TH ") []DESTRUCTIQN (cllaPRESSURE GETOUT <br /> OVER-BORE type below) <br /> SOIL BORING# Q PR <br /> WELL# w— Q UR <br /> 'other, Grout Specifications <br /> COMMENTS u i` W015 <br /> TYPE OF WELL INSTALLKnON TYPE CONSTRLIC`nON SPECIFICA730NS it <br /> '0 ONITORING �IOLLOW STEM PIA OF BOREHOLE r MULTIPLE C ASIN 'C YES 'ANC WELL CASING D1A:�_ <br /> *AIR <br /> RACTION q AIR HAMMEPJDRIVEN CASING THICKNESS sc�e�`' -� E OF CAS NG p STEEL c QT}1ER <br /> OR ©MUD ROTARY DEPTH OF GROUT 5EAL �� TREMi TYPE TO SE US XAUGERS �HOSE <br />' SPARGE Q PUSH POINT GROUT SEAL PUMPED )01es 17 Na {NOTE. VIAXIMUM FREE-FALL DEPTH IS 301 <br /> Q SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br />' p OTHER_[]OTHER APPROX BCRJNG DEPTH OLTF-D TRAFFIC SOX or U STOVE PIPE <br /> p CONDUCTOR CASING PROPOSED?�V t3 - (d E5.fist specifications here) <br /> 'COMMENTS L V le n } <br /> -01 <br />' NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCR 6 ACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 43 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />' I hereby certify that I have prepared this application and thatthework will be dona in accordance with San Joaquin, <br /> County Ordinances, Rules and Regulations, and all applicable CalifOrnla State La ivs, oy ol(to <br /> Signed x litlelCarnpany �'• � 1 <br /> S� C� o ,�,�an <br /> r7nrtt Name <br /> DEPARTMENT USE ONLY <br />' SITFE MAP IN UNIT IV FILE,ADDRESS: t G <br /> WORK PLAN BATED: Janp. it --ea <br /> Date Issued U Area Y <br /> RpplaC3taon Accepted By <br /> Grouk Inspection Fay ` >SateT, Final Inspea�eori BY <br /> Destruction Inspection By <br /> Date <br />' COMMENTS I CONDMONS C TLjGt C S <br /> 4red. c <br /> GOgNn :10NY AID#COINI.O AMGuNT REMn-rED CHECKS 7RMr-_c, Y DATE P 12Mrr!SERVICE"REQUEST# INVOICE <br /> p � <br />' C-57 WC --WAIVERC-57 Letter• of Authorrzatlon to sign per tI1It �ncroacflrtterlt doc 9/2-7/00 <br />