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07/03/2063 16 53 2694683433 FIFTH FLOOR PAGE 63 <br /> �` ELL PERMIT APPLICATION FORM SITE <br /> i r��I V ,� SAN JOAQUIN COUNTY MITIGATION <br /> • ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JUN 1 $ 203 304 E. Weber, Third Floor, Stockton, CA,, 95202 <br /> ,y\!'01EN f HEALTH (209) 468-3449 <br /> " <br /> ,1,14T/SERVICES NON-REFUNDABLE PERMrr EXPIRES l YEAR FROM OATEISSUED <br /> Appl'cation is hereby made to San Joaquin County for a permit to construct and/or install the work descrlbed ThIS appl'catlon is made in compiianoe with San <br /> Joaquin County Development Thio,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department-Assessors <br /> WELL LncaUan '9� v <br /> J%G4pr �wK+�t, .0 �: _Z1p`tiz Parcel#�1 _C_1_d 3Z <br /> � Gross Street �Y_/-ao . <br /> ,, ,a,., a `�4�I Phone S 3 -�1a <br /> PROPERTY Owner ttt W t4�q.*�-� �Olcr 5 t'` ddressZ�� w 4�� City P <br /> Oso �ot..•� �- c�ly L p��I_'c#Ygs16�Pt,anelt r_s 3r3-s�� <br /> C-57 Contractor r [J+ re`s <br /> L 4 7- ary_C i.^0. Uc* honali Z3S-y850 <br /> Consultarrt/Sub Cnu ��+�'�O�' a Address �� S� <br /> GIS Coordinates X Y,.Township Range sect'° <br /> WORK TO BE PERFORMED <br /> ANEW WELL I BORING (CPI-,GEOPROBE HYDROPUNCH,HAND AUGER,OTHER'} []DESTRUCTION (choose type',slaw) <br /> Q OVER-BORE DIAMETER <br /> 0 501E BORING# � <br /> , <br /> ;gwELI# �--�- 3 r•• 1 .��-tf p PRESSURE GROUT <br /> n VYELL GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL IN§jALI Allo TYPE CONSTRUCTION SPEGFICATIONS 11 <br /> MONITORING `gHOLLOW STEM DIA.OF BOREHOLE Vii' []MULTIPLE CASINGS gMULTI-LEVEL WELL CASING DIA <br /> d EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS��ga TYPE OF CASING (]STEEL PVC (]OTHER <br /> OR []MUD ROTARY DEPTH OF GROUT SEA '96" TREMIE TYPE TO BE USED $AUGERS []HOSE <br /> MSPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED XYes []No((NOTE' MAXIMU LM FREE-FALL DEPTH 15 3t]'� <br /> j]SOIL BORING []HAND AUGER GROUT SPECIFICATIONS_ Qor <br /> []OTHER ©OTHE APPROX.BORING DEPT DOL BOLTER TRAFFIC 80X or (]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A/O, (it YES,list specifications in oornment section) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPl=CTIONS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable Californla State Laws - <br /> Signed x <br /> -� Title/company - r— S-fQ-K Gaafo ' r' <br /> Date_ I <br /> Print Narne �G ' ' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILL, ADDRESS.' <br /> WORK PLAN DATED' <br /> Oats Issued 'A' res <br /> Application Accepted By Data <br /> Grout Inspection By ate Final Inspactlon W <br /> D&Vruct on Inspection By Date <br /> COMMENTS f CONDITIONS <br /> CCOUNTING ONLY AIDS FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECICtI EC'D BY DATE <br /> PERMIT/SERVICE REQUEST M INVOICE <br /> 3a�1 S .offILI SR# 3 <br /> G-57 WC -WAIVER C-57 better of Authori ton 0 sign pe mit Encroachment doc 9/30/02 <br />