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02/23/2081 10.05 2094683433 <br /> FIFTH FLOOR <br /> F' k�Et2`�- ' ! <br /> is WELL PERMIT APPLICATION FORM SITE <br /> p AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E.Weber, Third Floor, Stockton, CA., 3202 <br /> (209 488-3449 <br /> tiON•IREFt1NDAHtt"x PENTEXPIRES 1 YJ Aft FROM DATE 1S5UlxQ f�L <br /> WICabon M hereby made tt)San Joaquin County for a permit to construct andlor install trio✓work desenbed This application to made in cornpkance Vnth San <br /> oagm County Dc"to rnent Title CRapter 0.1115 3 and the Standards of San Joaquin Covnty Public Health Services,Environmental Health Clfvaion <br /> Assessoes <br /> HELL Locatla JJyy�� (;rpss/S�trienet IJ` ,tie may, City l� M1 Zap' `-�C�Z Parceb! <br /> 'ROPERTYOwne C.D ! dress !p/Y City 5- d/m Zip z Phon <br /> C-57 Contractor 01 <br /> Axd ✓) __Address t .1 /`Z• C� 40 11999uc4M?hon !03 <br /> Consultant I Serb Contractor rr Address i�f � S�rr� $.., JC,ty a ��aA Lica+ �Y Phon0*_1i2Z-�5`1- <br /> GIS Coordinates X Y ,Township Range Seedon <br /> WORK TO SE PERFORfta <br /> Q NEW WELL!BORING(GFT GEOPROBE HYDROPUNGH HAND-AUGER OTHER-) Q DESTRUCTION(choose"a below) <br /> OIL BORING 4 13-Z, B`� , ��^ (I OVER-BORE <br /> WELL �r Q PRESSURE GROUT <br /> COMMENTS <br /> 'Other Grout Speafiearions <br /> PE QF wtu Ifd AGM ION TYPIE CONAIRUCTIQL4 r2PEOrIC&TTONS <br /> U MONITORING I)HOLLOW STEM DIA OF BDREMOLE_2!!__MULTIPLE CASfNG5a D Y>`S ONO W ELL CASING 01A <br /> CTION 13 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OFCASING Q STEEL. i]PVC 13 OTHER <br /> _ <br /> ArR Q MUO ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED Q AUGERS 11 HOSE <br /> a AIR SPARGE j PUSH POINT GROUT SEA€.PUMPED 11 Yes D No (NOTE MAXIMUM i`REE-FALL. DEPTH (S 301) <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER tj OTHER APPROX BORING DEPTH BOLTED TRAFFIC BOX or [)STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (it YES,list speaficatcons hem) <br /> 'LOMMEWS - — --� —- - — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify that I hake prepared this application and that the work Vill be done in accordance with San Joaquin <br /> County Ordinance lull nd ulatlori and all applicable California State Laws <br /> Signed TMe/Company. rc�c- <br /> Print Name Date „3LO 1 <br /> _D,,//Ey�PARTMM`ENT USE QN�Y <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> _" <br /> WORK PLAN DATED: �- 0/ <br /> APPlicatranAccepledBy Date issued , ,o'-vZ <br /> Grout tnspecttan By,__ <br /> y Date Final Inspection By�_ — Clare <br /> Destruction Inspmllon BY ate <br /> gNIMENTS!Ct314orTIONS <br /> OUN'TtNG ONLY AID# 1 <br /> PECODES FEE INFO AMOUNT REurrTED CHECK# RLC-0 By HATE PER <br /> !SERVICE REgU>!:S T# ISyVO10E <br /> C-57 W1 -WAIVER C-57 Letter of Authorization to Sign permit Encroachment dos 9/27/00 <br /> 00 <br /> 2084683433 PAGE 002 <br />