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02/23/2001 10:05 20946834' FIFTH FLOOR C Ep4gapy <br /> Not <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ) <br /> 304 E.Weber, Stockton, GA-, <br /> O F0 C� <br /> (209) 468-3449 v fi <br /> NON-REFUNDABLE PE11 <br /> MIT EXPIRE-S_1YE FROM DATE ISS s a application is made In compliance with San <br /> >ppiicatlon is hereby made to San Joaquin County for a permit to construct and/or install the work described �' Assessors <br /> Joaquin Cou ry Development Tide,Chapter S-1115.3 and the Standards of San Joaquin County Public Health Services,EJ`nv nmepna Health Division. <br /> !�p Cross Street -r n Try <br /> HELL Lricatlon P phone# <br /> lD cityp.�-==' <br /> f e vl ddress �� t Q7L�CL_ 7.563 <br /> PROPERTY Owne -�� � /)I ic41f7D-� -inone - <br /> h5CRAddress �p pbon Z Z <br /> C-57 Contractor �.��Ciry �� I� L!c#� <br /> 2 ,.� Address���S rCr'�".A <br /> Consultant I Sub Contractor /- Range Section <br /> GIS Coordinates'X <br /> Y Township <br /> WORK TO BE PERFORMED: N -AU ER,OTHER') Q DESTRUCTIONp OVER type <br /> Q NEW WELL!BORING PRO13 NGYDROPUNCH, _ 0 PRESSURE GROUT <br /> 'WELL## Grout Specifications: <br /> *Other: <br /> COMMENTS: <br /> TYPE OF 11VE L INSTAU ATION TYPE CONSTy T�aN P FI TIONS O WELL CASING DIA: <br /> PIA.OF BOREHOLE MULTIPLE CASINGS- Q YES OTFtER:�_ <br /> Q MONITORING Q HOLLOW STEM �fPE OF CA51NG: D STEEL Q PVC [] <br /> AIR HAMMERrDRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: Q AUGERS HOSE <br /> a EXTRACTION Q DEPTH OF GROUT SEAL <br /> Q VAPOR MUD ROTARY <br /> I Q GE PUSH POINT <br /> GROUT SEAL PUMPED: � <br /> AIR SPAR Yes Q No (NOTE: MAXIMUM FREE-FAl.-1-DEPTH 1S 30' <br /> t CONDUCTOR CASING PROPOSED?_ <br /> ❑ GROUT SPECIFICATIONS: <br /> APPROX.BORING DEPTH'— O BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> SOIL BORING HAND AUGER <br /> 0 OTHE � <br /> R: �Q j_— � <br /> OTHERIf YES,list specifications here): <br /> 'COMMENTS: <br /> OTE: OFFSITE BORINGS REQUIRE ACCESS ORE FOROALL EQUIRE�NSPECTSIONS. <br /> CALLTHE UNIT IV INSPECTOR A8 WORKING HOURS IN ADVANCE done in accordance wit San Joaquin <br /> 1 hereby certify tha prepared this application and that the work will be <br /> an 4n and all applicable California State Laws. �r <br /> Count40rdina;_c9=S,,;re! 7lue/CompanySigned DatePrtntNa �"� DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE, ADDRES� l�"� <br /> WORK PLAN DATED: Z- <br /> .- a <br /> Date Issued <br /> Application Accepted By Date Final Inspection By _ <br /> Grout Inspection By <� <br /> Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDC# PERMIT I SERVICE REQUEST A INVOICE <br /> RECD BY DATE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK S <br /> �/ �', <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc9/27/00 <br /> � <br /> FEB 23 ' 01 10 : 00 2084683433 PAGE . 002 <br />