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02/23/2001 10:05 209468343 FIFTH FLOOR PAGE 02 <br /> PERMIT APPLICATION FORM St'TE 'N` " <br /> WELL MITIGATIO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEAoLoTHStlVISION ockton, CA-95202, <br /> 304 E-Weber, Third F ON ' // <br /> (209) 468-3449 <br /> YE FROM DATE ISSU D compliance with San <br /> NON-REFUNDABLE PE MR EXPIRES ,s application is made in comp <br /> application is hereby made to San Joaquin County for a permit to construct endlor install the work described. s ce Assessors <br /> ois Development Tide.Chaplet ou t t5.3 and.the Standards of San Joaquin County Public Hoalth 5ervices�ES�nmePna sessbes Division. <br /> Joaquin c tY9-1115 <br /> �v,o _city 57�k oh zipf <br /> 8W eew <br /> Cross Street' fE„ �S� Phonelt <br /> WELL Location- 7Jp_�� <br /> —(-O5L0 Address_ 138 Lcc� IiU FJ< 5�•k �1City osc�tl jr7 72- 3� Y3� <br /> PROPERTY Owner Z�9NS7( Licel 10� Phone a <br /> r� ` v, is cj2 }SSS- <br /> C 57 ConUactor �wlar�-�►- Addross� Q �1 C'ry '•fc$ v� Lic#22a �1 phoneifC- <br /> �1t(.• Arridress� <br /> city <br /> Consultant!Sub Contractor_ Range Sectlon <br /> .Y .7ownsh�P <br /> GIS Coordinates:X below) <br /> WORK TO BE PERFORMED: ❑DESTRUC ftOt`1(choose typo <br /> Q OVER-BORE <br /> Nd uEW WELL 1 BORING(CPT.GEOPROSE.HYDROPUNCH.HAND-AUGER,OTHER') 0 PRESSURE GROUT <br /> Q SOIL BORING ft_ <br /> WELL a Grout Specifications: <br /> 'Other. <br /> COMMENTS: t� <br /> INSTALLATION TYPE CON TR CTI N P I TIONS ? NO WELL CASING DIA:Z_ <br /> TYPE-----�F W LL DIA.OF BOREHOLE �AULTtPLE CASINGS. <br /> HOLLOW STEM OTHER:__ <br /> MONITORING AHOSE <br /> EXTRACTION o AIR HAMMERlORIVEN CASING THICKNESS Saba y0 TYPE OREM EI TYPE TO SE USED: Q AUGERS <br /> 0 DEPTH OF GROUT SEAL ar- — <br /> Q VAPOR Q MUD ROTARY No NOT MAXIMUM FREE-FALL•DEPTH IS 30') <br /> PUSH POINT GROUT SEAL PUMPED:` Yes Qn <br /> 0 AIR SPARGE Q �w <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: abs <br /> APPROX.50RING DEPTH BOLTED TRAFFIC BOX or ()STOVE Pl <br /> PE <br /> i YES, . <br /> 0 OTHER:_ OTHER,_ Inst speafi-ations here): <br /> CONDUCTOR CASING PROPOSED? (6-9 1 x e u <br /> 1� o <br /> •COMMENTS: <br /> ENCROACHMENT PERMITS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS O CE FOR ALL-REf?U RED INS EC ONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVAN <br /> dance with San Joaquin <br /> t have prepared this application and that the work will be done in accor <br /> 1 hereby certify that 1 hales an gula ' ns, and all applicable California State Laws. <br /> County Ord ina s, r <br /> Tltlejcompany l0 <br /> Signed <br /> Print Name u/ DEPARTMENT USE ONLY <br /> Jia <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ' • O <br /> WORK PLAN DATED' Area 4 J <br /> Date Issued patef= <br /> Application Accepted BY pate Final Inspection BY- <br /> Date <br /> y <br /> Grout Inspocilon By Date <br /> Destruction Inspection BY <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID* pERMR I SERVICE REQUEST 0 INVOICE <br /> RECD BY DATE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK i -��-0 t Z ^ v <br /> 35DI - � 05 036 (doc 9/27/00 <br /> C-57_ WC;WAIVER_. C-57 Letter of Authorization TO sign permit Encroachment doe_ <br /> FEB 23 ' 01 10 :00 2094683433 PAGE .002 <br />