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11:16 2094683433 FIFTH FLOOR GAGE 0n <br />WELL f✓l:�RMIT APPLICATION FORM <br />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-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED <br />_af;cation is Hereby made to Sar .ieaquin County for a permit to construct and/or instait the work deaeribetr. This application is made in compfrance with San <br />:aauin County Development Title, Chapter 9-1115.3 aria the Standards of San joaqui Count/ Public Health Services, Environmental Health Division. <br />7/2 •` . 'Sr � n <br />`A55855ors'ELL Location �, Cross Street _Av zip��parcel# <br />RCPERTYOwner C/ry Of 7M(fY Adddro$$-'�� TRACY (3L. �ciityy '72i ACi Zip .1376 hone# 03,!'�4g60 <br />�7 .antractor 1 44dLrass I �� 11J� I 1 Clryrd��L.,�.. Zip y liCo. 5� PhG�n� 77-4U <br />ii ,, II ��(( ((��JJ L IiG <br />onsultant / Sub ContractorW (I U1 AL't:f§3t�� iX" %. I u� 5� City I nAC..Li ucz b5�'5o ( Phnnet! mom\ SC�� 117C <br />IS Coordinates: X Y Township Range.. Section <br />'ORK TO SE PERFORMErJ: <br />NEW WELL! BORING (C -T. GEOPROSE. HYDROPUNCH, HAND -AUGER, OTHER'; [I DESTRUCTICN (choose type below) <br />SCIL 30RING # (I OVER -BORE <br />ELL # U PRESSURE GROUT <br />lther_ GROUT 5PEC11=iCATION <br />OMMEN T S: <br />I'PE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />(I HOLLOW STEM <br />FX7RACT[ON <br />Q AJR HAMMER/ORIVE N <br />VAPOR <br />gMUZROTARY <br />a Fr SPARGE p PUSH PC_[Nj <br />SOIL B0RING Q HAND AUGER <br />OTHER: Q OTHER <br />0 NVAENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF 30REHaLE MULTIPLE CASINGS?17- <br />Q NO WELL CASING D:A:�� <br />CASING THICKNESS TYPE OF CASfNG: [I STEEL 0 PVC [I OTHER: <br />nEPTH OF GROUT SEAL TREMIETYPE TO 85 USED: Ii AUGERS ` OI13E <br />GROUT SEAL FUMPEO; es 0:�{a�(NOT : M IMtIM F EE -FALL DEPTH IS 301) <br />GROUT SP,CIFICATION �o•�� <br />APPRC•X_ BORING DEP T ii IJ BOLTED TRAFFIC BOX or Q STOVE P1PE M/J- <br />CONOUCTOR CASINC P.ROPCSSn-% (if YES, list speciricatlrrs here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />hgfeby 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 />CAL H UNIT 1 NSPECTOR 48 WORKING HRS IN ADVANCE FOR #L,L)REQUIRE <br />INSPECTIONS <br />gr+ed x tit � � Titlelcomoanv !�1 P�iC�v'. 4 / 1%V rI o �•l k n t%1t�,r?l I wi- ki <br />ini Name ,j'o yx _ L unc-yv- _Gate_ I <br />SITE MAP IN UNIT IV FILE ADDRESS [WORT{ PLAN DATED <br />;p1iCation Accepted By Date issued Arad <br />mut inspecuon 6y ( Date. ? Fnaf inspection 8y <br />?Gtr -ion Inspection 9y date <br />DNINIEVTS ! CONDITIONS: <br />ACCOUNTING ONLY: I AIO# <br />�g C+JdE3 FEE INFO I AMOUNT REMITTED CHECK # REG'D BY I DATE ( PSW=J SERV E5T Ii I INVOICE <br />&D3 z, z, <br />C-57 WC/WAIVER C-57 Letter of Authorization to sign permit 7/17/00 <br />I� <br />Jf- <br />