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. 5A <br />WILL PERMIT 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 Cornu n <br />Application is hereby made to San Joaquin County fora permit to construct antl/or Install the work described. ISSUEA E This application 13 made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />,2U cV�tIS Jz� <br />WELL Location ciT7tictic,t S,T:c rn.:1 SIG ro.j <br />Cross Street L oru Lt nA City L Ud I' Zipc{S 2( Assessor, <br />PROPERTY Owner 2-21 W , 7Parcel# <br />iT�y L O cl i Address `S, �'' � ` .S -i, - <br />J�v rem sT^:.,7cf ,�sa� -7 I. r Loci; zip9s2�t1 Phoneu L[;y 333 1ik�p <br />C�7 Contractor CA I - L-110 -J .2,.Ar , Address W e T Sccc Rv�te^1 !'�c <br />Il p k Cit ySc;c::,m44?gip!9'il Lic#5 221cffrPhonedc(I1, 373-II1Fr <br />Consultant; Sub Contractcrflen-41"'+ `Address ii�S7Sp:MJ)��%sl (�j-20G <br />vc� :Jity0,;bit�l Pr clY—Ph (In) -SEI -7272. <br />GIS Coordinates: X _r bone# <br />• Y ,Township -- <br />Range Section <br />2( W K TO BE PERFO MED: <br />NEW WELL / BORING ( CPT• GEOPROBE, HYDROPUNCH, HAND -AUGER. OTHER-) <br />[I SOIL BORING # 0 DESTRUCTION (choose type below) <br />'Other: 0 WELL # L)OVER-BORE <br />COMMENTS: r t -r✓ „L 1 :. A — r <br />Grout Specifications: 0 PRESSURE GROUT <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />*OLLOW STEM <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE <br />0 PUSH POINT <br />11 SOIL BORING 0 HAND AUGER <br />O OTHER: -__0 OTHER <br />. C4,,1int, Tca..1 S t/d <br />"o j <br />-o <br />_ _ O <br />CONSTRUCTION SPECIFICATI Ns <br />DIA. OF BOREHOLE 7 S <br />MULTIPLE CASINGS? (] YES *0 WELL CASING DIA; Z t jf rr <br />CASING THICKNESS SC_h( `f J TYpE OF CASING: 0 STEEL gVC 0 OTHER; <br />DEPTH OF GROUT SEAL 1� -S� �i c�tc� TREMIE TYPE TO BE USED: AUGERS 0 HOSE - <br />GROUT SEAL PUMPED: -ees 0 No (NOTE: MAXIMUM FREE -FALL DEPTH I. <br />GROUT SPECIFICATIONS._iQ0^"Pluwc( `� <br />/.r \I 1T /1i.ct•% <br />APPROX. BORING DEPTH -7S' CA— rte., --.-- <br />CONDUCTOR CASING PR POSED <br />>'\� CATTtaG�C1� wC�� Co .1�•Tr(if Y <br />jc-rta Jt q NO or 0 STOVE PIPE <br />ES, list C`Q7�Y' 1 . <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 />1 hereby certifyt I ha a repared this application and that the work will be done in accordance with San Joaquin <br />County Ordin�tt s, nd Regulations, and all applicable California State Laws. <br />Signed yp <br />(n� .---- Tit!?/^mm�a.. �('V ..7 <br />nC', �, �' — --- y--� / ccl4tc,e^—14cAs,6a.,.r,�CSoci��s,2c. <br />Print Name �--- `�' <br />Iis-LaA — -"- Date 2; ruu <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By Date Issued�?�d tJ Area ✓2s. p LL3 <br />Date DO Final Inspection By <br />Destruction Inspection 8y Date_, �D <br />Date <br />COMMENTS / CONDITIONS:_ . ld-If <br />ACCOUNTING ONLY: AID# <br />tPECODES FEE INFO AMOUNT REMITTED CHECK #RECD BY OATS Sit �1- t '7 lam— 11 Vo <br />C-57_ WC_ <br />-WAIVER_ C-57 Letter of Authorization to Sign perm <br />Z9 3SVd d00 -1J H1iT-9 <br />EEbE89b69Z <br />INVOICE <br />t7 9/27/00 <br />Eb:01 909Z/EZ/91 <br />