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02/13/2001 08:36 2094683433 FIFTH FLOOR PAGE 02 <br />WER PERMIT APPLICATION 40 <br />FARM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468.3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application 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 />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />WELL Location Q 0 Cross StreetLB i Ci -^/� Assessor's <br />ty pt, Zlp Parcel# <br />PROPERTY Owner �' 61"j-fA*LS <br />Addtess P•0 • 204 City - n Tw 'Zp %lab Phonee# <br />CS7 Contractor Cityi Phona�� <br />Consutant/ Sub ContracoWitLl_ # <br />Address I �� G IZA" Iii✓ . City a�� tJc# Phone# S)a ZS/- 2$$'� X Z16 <br />GIS Coordinates: X Y , Township Range Section <br />WOK To BE PE KQRM <br />EW WEU.! BORING CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) a DESTRUCTION (choose type below) <br />0 SOIL BORING # U OVER -BORE <br />[I WELL # tj PRESSURE GROUT <br />"fir: Grout Speaflcation5: i - <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />FEE INFO <br />0 MONITORING <br />n HOLLOW STEM <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES [I NO WELL CASING DIA: <br />INVOICE <br />0 EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER: <br />`#L) ; t�) C� <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br />0 AIR SPARGE <br />n PUSH POINT <br />GROUT SEAL PUMPED: Yes []No (NOTE; MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS: <br />0 OTHER: <br />HER <br />APPROX. BORING DEPTH S"D _ p BOLTED TRAFFIC BOX or U STOVE PIPE <br />t <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />*COMMENTS: <br />O <br />NOTE: <br />OFFSITE BORINGS <br />REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby cprtily that I have prepared_ this application and that the work will be done in accordance with San Joaquin <br />County Oddi ces, Rules nd R ulations, and all applicable California State Laws. <br />Signed x � �:1 C- TitlelCompany j 1 6�L , /c� <br />Print Name / `C -'L7 Lia. /W e-1— Date ?/�/0'/ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: I I Li F1 1 LD QA -*— <br />WORK PLAN DATED: A10 V I .A .t9 C <br />Application Accepted By Odie Issued 4� I ( Area <br />Grout Inspection By-12,422Lj Date b -8-c9 ( Final Inspection By---- Date <br />Destruction <br />COMMENTS 1 C <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOOUNT REMITTED <br />CHEECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />L <br />`#L) ; t�) C� <br />� 7 <br />C-57 WC_ -WAIVER_ C-57 Letter of Authorization to sign permit. Encroachment doc . 9/27/00 <br />