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10 07/22/2003 08 46 2094683433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> P1v � MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> c ' ENVIRONMENTAL HEALTH DIVISION (PWS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA,, 85202 <br /> s �paa 5° nas�o+� (209) 468449 <br /> � <br /> NON-REFUNDABLE PERMIrr EXPIRES_ YEAR FROM DATE ISSUED <br /> Appl ton is hereby made to San Joaquin Cuurity for a permit to consb'uct andfor 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 Servim.Environmental H tth Division <br /> WELL Location /g� 7 ge Cross Street f!'-CItY zip � Parcel# /�'�'^0��a/ <br /> PROPERTY Omer <br /> 'f�+ Address„ d, ziP�OmerPhone3# <br /> C-67 Con#racGor rl.. 71rei...rl <br /> Address Gly_ �? 7J p Llc# S Phone#_!6 --�'/ ' <br /> Consultant 1 Sub Contractor 7� -0 - _ Address ' j �fi16rCrtyLf�k Phone# ��6 �"'�li� <br /> GIS Coordinates X Y------.Township Range„ Section <br /> WORK TO BE PERFORMED <br /> Q NEW WELL l SC)RING(CPT,GEOPROBF,HYDROPUNCH,HAND AUGER,OTHER-) a DESTRUCTION(whom type below) <br /> [l SOIL BORING# p OVER-BORT: <br /> jl�NELL# — _ p PRESSURE GROUT <br /> „Other Grout Specfficabons <br /> COMMENTS <br /> ETE OF WE INSTALLATION TYPE GONSTRU T N SPECIFICATIONS <br /> (I MONITORING XHOLLOW STEM DIA OF SOReHOLE $ MULTIPLE CASINGS"BYES)10 WELL,CASING DIA <br /> II EXfRACTiON AIR HAMMF-PJDRIVBN CASING THICKNESS-, TY�E OF CASING []S7EEL I]PVC 0 OTHER <br /> APOR D <br /> MUD ROTARY I7I=PTH OF GROUT SEAL-. TREMIE TYPE TO BE USED .AUGERS p HOSE <br /> �R SPARGE PUSH POINT GROUT SEAL PUMPED aYes '<No (NOTE.MAXIMUM REE-FALL DEPTH IS 30') <br /> IL BORING Q HAND AUGER GROUT SPECIFICATIONS ✓ �� �� <br /> p OTHER (]OTHPR� APPROX BORING DEPTH , BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> �f�NDUCTOR CASING PROPOSED? 01 (BYES.list specification�s�here) <br /> -COMMENTS Z Z— �' 6✓ 96 D a/i 4 o2G 1i�"G4r rV A;Le't <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the worst will be done In accordance with San Joaquin <br /> County Ordinances, ufss nd Regulations,and all applicable California State Laws <br /> Yitle/Compeny-,_--,,... Ar - <br /> Signed x / <br /> Print Name �� — Date —/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT!V FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date IssuttCl Area— <br /> Grout Inspection Date Final Inspoobon By date <br /> Destruction In$P9cll0n BY Date <br /> COMMENTS 1 CONDITIONS <br /> Aocou INo ONLY AID# carer <br /> E CODES pF-E INFO AIIMOUNT REIMITfED GtiECK# j REC`D BY j BATE PERMIT/SERVICE muE9T# INVOICV <br /> dpi Sj-OU 5- o 101 a3 SRO 3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign perttui'_Encroachment doc__ 9/27/00 <br />