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_Date Issued — \ Area -94- <br />Date Final Inspection By`/ <br />Date <br />ACCOUNTING ONLY: A1D# <br />plication and that the work will be done in accordance with San Joaquin <br />and all a. • icable California State Laws. <br />Ti11e/Company .P:tA1/4"t IrThot—AtAgrip... <br />Date <br />DEPARTMENT USE ONLY <br />I hereby certiat I have prepared th' <br />County Or Kances!Rules and Reg <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />PE CODES FEE INFO <br />..mft• <br />AMOUNT REMFTTED CHE <br />I4 <br /> 7=. <br />C-57 <br />(to 1 <br />WC -WAIVER C-57 Letter of Authorization to sign perm 9/27/00 <br />CK <br />FAC# <br />REC'D BY <br />Signed x <br />Pnnt Name \ CC kl nr- <br />• <br />COMMENTS / CONDMONS: <br />Pe7-;1- 6-Li 4717 <br />PER ERVIE,E-REQUESTIr - —INVOICE DATE <br />12/07/2000 10:42 <br />20946834.33 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <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 />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 Coun •evelopment Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. Assessor's / — I 0 <br />W?LL Locatio Cross Street C <br />n <br />ITY Li".44‘ny Zip Parcel# <br />0 <br />Consultant I Sub Contractor cklress Li t\i .TL151-L4 <br />GIS Coordinates: X Y , Township Range Section <br />SITE <br />MITIGATION <br />UNIT IV <br />Ade.c!rlsrie)61, 1S-ci CItY IJJ09-AU1- (-14- ZIP`f Phone <br />PROPERTY Owner l iriC.C.cy. ... 'iann <br />C-57 Contractor A,Viresr\ s S.319 Mica.,10.204. city NA4te,:v4ipi_03013Licatkio )9:140nes Lew) YYS 3 <br />City Tos+ vLic.# prione# 0126-66.s 2— <br />WORK TO BE PERFORMED:. <br />D NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />'SOIL BORING # b cwt4O _1.40(-4 I:024 <br />.0 WELL # <br />'Other. <br />COMMENTS: <br />0 DESTRUCTION (choose type below) <br />U OVER-SORE <br />PRESSURE GROUT <br />Grout Specifications. <br />TYPE OF WELL <br />fl MONITORING <br />EXTRACTION <br />()VAPOR <br />fl AIR SPARGE .SOIL BORING <br />Ofl THER:_ <br />tpISTALLATION TYPE <br />fl HOLLOW STEM <br />U AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />0 PUSH POINT <br />u HAND AUGER <br />a OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES a No WELL CASING CIA:_____ <br />CASING THICKNESS TYPE OF CASING: a STEEL EI PVC U OTHER: <br />DEPTH OF GROUT SEAL TREM1E TYPE TO BE USED Q AUGERS U HOSE <br />GROUT SEAL PUMPED: °Yes O Ne (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> <br />COMMENTS: *COMMENTS: <br /> <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.