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04/10/2002 15: 36 2094683 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1pplfcatlon Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> oaquin County Development Title,Chapter 9-1115-3 and the Standards of San Joaquin County v�ronmenta Heatth Department_ <br /> PG,8 P- 1 a�hYo O e�y�.a4e c S�o Eisv, �4r k n-v� wa��-+„ s d u CLsod <br /> YELL Location P _� � � �'" Assessor's <br /> -L,7o -Ac- o w c rF 1 Cross Street city Zip Parcef# 191- 05 0- 10 <br /> �gva,c• 6 w-A.\tn <br /> . Scx,-t4.vrCa} clb �8.� <br /> 'ROPERTY Owner nA o y. �:(>pha\A Ze 1lonA re55 yoyo �i, a �d City 210 00mvxZip 9 5106Phone# <br /> :-57 Contractor V&W �rii�,i Y,.c•Address IOD�Ft1n SrY P•O•F�ox`�16 <br /> ity ;�skA-*�r. up`15/04.1 Lic#-7'1C'904Phone# 00 <br /> -onsultant/SubContractor_C�- a-�-AH\�-L Addressk55 GYOY� , A-ve.• ClryOak�whdLica# Phpng#>�`1�6��19-898Z-Gall <br /> Sw:ae. 10op CS�o� g�_ S �-uce'�c <br /> AS Coordinates:X Y Township Range Section AV-,. A• Fro,, c4�yL}p <br /> lORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) VIfIDESTRUCTION(choose type below) <br /> 0 SOIL BORING# V OVER-$ORE <br /> 0 W ELL# p PRESSURE GROUT <br /> ether: Grout Specifications: <br /> :OMM ENTS' w e1.f v�v � Lo kL`n tr� b��y�s-ke c SE�n s Y, (ween t nw Mw 9y�r.w 10> <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC BOTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> "R SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> AIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: p OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> `.OfUMENTS: <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 t have prepay this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances,RUI an egulations, and all applicable California State Laws. /��/' <br /> fined x Tibe/Company D�� / 1� fX0GIS7 <br /> irrt Name A/C(i(( T-, Date <br /> DEPARTMENT USE ONLY v� <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> IORK PLAN DATED: <br /> )plication Accepted Byw Data Issued q Z�O3 <br /> rout Inspection By to Final Inspection By p <br /> aSbvction Inspection By Date <br /> DMMENTS/CONDITIONS: • : :1 N Yav&I It <br /> w/ <br /> ACCOUNTING ONLY: AID# 114}' <br /> C6 f`i+ <br /> CODES FEE INFO AMOUNT REMITTED CHECK# ** sign <br /> PERMIT/SERVICE REQUEST# INVOICE <br /> 02 0. oo I o 12�ZSR# 51 <br /> -57WC=WAIVER_ C-57 Letter of Autho permit Encroachment doc_ 1/25/02 <br />