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08/03120130 11:16 -094683433 FIFTH FLOOR PAGE 172 <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 ORIG (209) 468-39 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />=pt,=tion is hereby made to San Jcaquin County for a permit to construct andlor install the work dascdbed. This Zw0cation is made i comptiance with Sao <br />=ion County Development Title, Chapter G-11'5.13 end the Standards of San icaquin County Puy lic Health Services, Envfronrnentai Hesith Civisw <br />'ELL Locations q S CO- -- l�'rn S+e-M Cross Street MM&OCi �3 AssE55ors7��� <br />CC ry ZrR A3$8# !� <br />ROPERTYOwner_EQ_f-I � �Ste;I) AcldrasS/��`��'`C&�S �L i� City, ZipaS�3JiQPhone#Q0 7 S �7` 27 <br />-57 Contrzctor�kW L=$ AddressPQ 62-K 4Ilo Clty� f�22 zip 2941 i `�090 Phone# J� �� CJ <br />WJ-Q1 GYI t^�:yes �^� <br />onsultant , Sub Contractor u rct\nnenr al Address (=1 E- 1Ctl� 5� feetity �iL�C Lic-1 I `a Phone#_, pIQQ Z 3 � 0'zJ� <br />IS Coordinates: X Y , Township Range Section <br />ORK TO BE PERFORMED - <br />NEW WELLBORIN CPT, GEOPRCBE. HYDRCPUNCH. HAND -AUGER, OTHER`; U DES -RUCTION ;choose type below) <br />SOIL BORING -. !S� 0 OVER -BORE <br />L 0 <br />)then: WE" r GROL,'T SPECIPiCATION PRESSURE GROUT <br />OMMEN S: <br />(PE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />! HOLLOW STEM <br />EX7RAC7I0N <br />G AlR HAit1M5PJCRN E <br />VAPOR <br />© MUD ROTARY <br />AIR SPARGE <br />0 PUSH PciNi <br />SOILBORING <br />0 HAiNC AUGER <br />07H, ER: <br />Q 071FER <br />CONSTRUCTION $AECIFICATIONS \ <br />DIA. OF 30REHOLE `i °` %iU'LT!PL? CASINGS?[] YES § NO WELL CASING DIA: <br />CASING THICKNESS k)jIr "YPE Or' CASINC: tj STcE! 0 PVC n OTHER: <br />DEPTH OF GROUT SEAL i REMIE TYPE i 0 E'sE JSZ0; D AUGERS lOSc <br />SPOUT SEAL. FUMPE--0,, III Yes 0,4c) (NOTE: MAXIMUM FREE --FALL DEPTH IS 30" <br />SROUT SS5CIF:CATI0N is�_k _ , ,Br-^ Q �Q QQ'� <br />-APPROX. BORING DEPTH �(� �5� j1BCL ED " RAF.F;C 3CX or U S T OVE PTFE <br />OONOUC70R CASING PRCPCSED? (if YES, ',1st spe6ficatic-3 here): <br />OMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />i ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />aunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />CALL THE UNIT IV INSPE OR 48 WORKING HRS IN ADVANCE FOP, ALL REQUIRED INSPECTIONS <br />,red x Title/Company <br />im Name M_0 r: (X-Ck Cate 3-2-3-01 <br />SITE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DATED <br />)plication Accepted By <br />r"t Inspection lay Date <br />astmcticn Inspection By Date <br />OMMENTS t CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />'E CODES I FEE INFO ; AMOUNT REMITTED i CHECK # <br />Flnef fnspec'tion ay <br />REC'D BY ! DATE <br />Date <br />-- <br />X I INVOICE <br />C -57I WC/WA^VER C-57 Letter of Authorizaticn to sign permi4 rt 7/17/CC <br />