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10/21/2082 16 15 2894683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM gI <br /> Ciel 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 S ! � <br /> il- <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR ROM DATE L5SUED <br /> Icaflon is hereby made to San Joaquin County fora permit to construct and/or Install the work described This application Is made In compliance with San <br /> luln County `"e Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> &2_ 1-1613YI-A a Assessor's pp <br /> 1 Location7'' ross Street dy I�! Zip Parael# Al <br />�PERTY Owner titi Address W/A Ci Zip Phone# <br /> ,�1�.0 <br />'Contractorcr�le Dri Address'WL 0 W CAW& City. 0 pq 7q76c#M3@QPhone# G30` Aq <br /> suitant/Sub ContractorSf e dress YG 100C1fit/Llc# Phone# f& t - <br /> Coordinates X N ,Y ��� Towrtsh�p Range Seoban_INA - — <br /> tK TO BE PERFORMED_ <br />_W WELL!BORING(CPT.GEOPROBE, OPUNCH,HAND-AUGER Q DESTRUCTION RUCTION(choose type below) <br /> II SOIL BOE_, G h OVER-SORE <br /> WELL#_ <br /> LAM(I�'I�KIVI-�S fl��I s PRESSURE GROUT <br /> or. / ✓1 afications V <br /> LAMENTS <br /> r crm �• <br /> E OF VYELL INSLALL_ATION IYE9 CONSTRU TION SPECIFICATION-9 t <br />)NI'TORING HOLLOW STEM DIA.OF BOREHOLE—_0_" MULTIPLE CASINGS?(I YES )(NO WELL CASING DIA Z II <br /> TRACTION Q AIR HAMMERJDRIVEN CASING THICKNE LV 0 TYPE OF CASING p STEEL XPVC 11 OTHER. <br /> []MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED []AUGERS 1]HOSE <br />�16GE p PUSH POINT GROUT SEAL PUMPED 1]Yes ' o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XL BORING 11 HAND AUGER GROUT SPECIFICATIOt�IS' <br /> ri IER' fl OTHER APPROX.BORING DEPTH Y I BOLTED TRAFFIC BOX or []STOVE PIPE <br /> {, CONDUCTOR CASING PROPOSED? if YES,list spedRcatlans.h'4 ) <br /> r IW 1 tb- s nd <br /> AMENTSpfirou <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 />,reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> inty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> ed x TittelCompanY C(, 5 S s n I✓ <br /> Name Y66 Date V <br /> 'Z — DEPARTMENT USE ONLY <br /> E MAP IN UNIT IV FILE,ADDRESS: '/654�V 6,0yj� W <br /> IRK PLAN DATED: —D Z. fa4i0fa <br /> kation Accepted BY —Date Issued l�rZf IQ� - _area �6�¢ <br /> d inspedian By <br /> pate Final inspection By Date <br /> mcom Inspedlon By Dale <br /> 1 CON0MoNS- <br /> d ONLY' AID# rarer <br /> CODES FEE IHFoAMOUNT REMrMD CHECK# REC'O BY DATE r" PERMIT 1 SERVICE REQUEST 9 INY010E- <br />,7 WC -WAIVER— C-57 Letter of Authorization fa Sign pel~mtt Encroachment doc 4/27/00 <br />