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10-24-2000 03:40PM FR 00 <br /> TO 15306766005 P.02 <br /> ORIGINAL WELL PERMIT APPLICA ION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC H TH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stoc ton, CA., 95202 <br /> (209) 458-3449 <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 County Development TifQ Ch,p SCL f}5.3 and the StandardsOfSan Joaquin Co my Public Health Services,Environmental Health Division. <br /> YYELJ.Loaatlor�b �� ��t l"�'t �'"t Cross Street r Assessofs <br /> t' itY o Zip Paroel# <br /> PROPERTYOwner_V 1 Q//A T/V5f Address I tTa p <br /> CC�-?� Q n ' City �Q�1 Zipl-75 .31 phonetf <br /> Cd7Contractor P/�IIi to Addrass55b A�V'G11tD+4A City, tDUi Zip/y571 Lir IJ1J0� Phone#707'37y'I?��' <br /> 33$� (Qw ua,P�tlC <br /> Consultant/Sub ContractorSys PV, <br /> t Address�� L{ yS6�2 phone# 5'r04%_.706.70617J <br /> GIS Coordinates:X ,Y ,Township 5 Range R 4 <br /> Section <br /> XW RK TOB >' F gyp:. <br /> EW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER•) U DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> �NJELL# Z 1]PRESSURE GROUT <br /> 'Other, Grout Spacifi tions. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATION <br /> ,XMONITORING gHOL.LOW STEM DIA.OF BOREHOLE I b 4 M LTIPLE CASINGS?13 YES ,11 NO WELL CASING DIA: <br /> A EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESSS 4 TYPE OF CASING: U STEEL kPVC BOTHER: <br /> a VAPOR A MUD ROTARY DEPTH OF GROLIf SEAL b2 rn,41 TREMIE TYPE TO BE USED: a AUGERS Q HOSE <br /> 17 AIR SPARGE o PUSH POINT GROUT SEAL PUMPED: kYesNo,(NOTE: MAXIMUM FREE-FALL DEPTH iS 30') <br /> 0 SOIL BORING 17 HAND AUGER GROUT SPECIFICATIONS: k4 <br /> a OTHER.-_8 OTHER APPROX.BORING DEPTH 1 (0 Af#A!j 0OLTED TRAFFIC BOX or p STOVE PIPE <br /> C NDUC/TpR"C/ASING,P�7p-POS 1'10 (if YES,lists if ti. here; <br /> 'COM ENT IIS will i vnmP(.Ji Qq 4t,r�y {D /nudl/tl Ogti (5p aC <br /> d /'w1 40�0) 1 c - (✓ (wn. <br /> NOTE: OFFSITE BORING REQUIRE ACCESS 311 ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADV kNCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the wor will be done in accordance with San Joaquin <br /> County Ordi Sanntes, s#u)!�s and-Regulations,and all applicable Califo is State Laws. C/ <br /> Signedx -i,ry'IAII.''_.. [rN" ... Tille/Compan i (RAW77 J7/ Poo �, <br /> Print Name 4 id'' <br /> DEPARTMENT USE Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 25775 S, F G SS <br /> WORK PLAN DATED: , IS�O--Gl�'(Eo� ; --20,97 <br /> Application Accepted By N)ue\ _t 7-eutll�<«`'L Date ssued 494/13A) Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# / <br /> PE CODES FEE INFO AINOUNTREMITI'ED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 50 371j <br /> C-57_ WC -WAIVEP._ C-57 Letter of Authorization to sign permit—Encroachment doc_ 9/27/00 <br /> TOTAL P.02 <br />