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10-24-2000 03:40PM FR� <br /> �* <br /> r TO • 15306766005 P.02 <br /> O R t O1 NA L WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SITE <br /> MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> UNIT IV <br /> 304 E. Weber, Third Floor, Stoclkton, CA., 95202 <br /> (209) ,468.3449 <br /> APPficafon is hereby made to San Joaquin CoON•Runty o aUNDABLE PERMIT EXPIRES t Y FROM D TE ISSUED <br /> Joaquin County Development Tit/l-e,Chapter 9-1115-3 and eit to con Standas of San/Joaqu11 the County Public des abed.HealtServicesi Environmental Health compliance <br /> San <br /> WELL LocallonIU )0+1 �/ M <br /> pp Cross Street Ls�5_(��r}11 it, j. n� Assessor's <br /> PROPERTY Owner �J�(/) •1 --T--ZIP Parcel# <br /> Adtlress1G'" iP P � �--- <br /> C,57 Contractor CItyZIP +Z Phene# <br /> fC, Address !� � --�_, <br /> J1(6a bv.L 01 r (/ �Pyyni Lic#7ltd 1 Phone#_,Consultant/Sub Contractor ' y, 3��� % ( c /� -yam <br /> Address ' City( N}t,lN {G# `�✓JL <br /> GIS Coordinates:XA � Y <br /> —•---.•-..�.-._._.Township Range L <br /> WORK TO BE PERFOR D_ _Section�___�___ <br /> R NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> 0 SOIL BORING# DESTRUCTION choose ) <br /> 0 WELL# ( type below <br /> `Other; , ,OVER-BORE <br /> COMMENTS: pf,I Grout Specifications: 11 PRESSURE GROUT <br /> ✓Ylte- 4yd/-17 I <br /> TYPE OF WELL INSTALTIONT PE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 'AHOLLOW STEM DIA.OF BOREHOLE l <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS MULTIPLEIf <br /> CASINGS?R YES,ONO WELL CASING DIA:Y <br /> /APOR 0 MUD ROTARY _TYPE OF CASING: O STEEL XPVC O OTHER: <br /> DEPTH OF GROUT SEAL q, <br /> 11 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: _ --TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 SOI,BORING 0 HAND AUGER Wyss11 No .(NOTE:MAXIMUM FREE-FALL DEPTH 1S 30') <br /> GROUT SPECIFICATIONS; I�f�ytta+t.�' <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH <br /> I CONDUCTOR CASING PROPOSED? O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'COMMENTS: �/ I VIU_lS - (if YES,list specifications here); <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan es, Rules and Regulations,and all applicable California State Laws. <br /> 1 rl / <br /> Signed xL ' p✓'�✓/ Title/Company +�t57 />'7r�1S rfa; Tjj4 <br /> Print Name ('GN!�1t7,}li.,yi <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z7 77 j' K <br /> ,1 <br /> WORK PILIN DATED: ,, 11 iS QG l"oyeo �'pU <br /> APPlication Accepted By IV SCI STP u ci'c�� <br /> Grout Inspection By Date Issued Area Q y <br /> Final Inspection By Date <br /> DesaucGon Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> [ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD BY DATE PERMIT/SERVICE REQUEST$ INVOICE <br /> r. tr rf., r fyq C/u oa � 7 Q �t 3 <br /> C-57--- WC WAIVER _ C-57 Letter of Authorization to Sign permit_Encroachment doc_ <br /> 9/27/00 <br /> TOTRL P.02 <br />