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04/1r1/2901 19:28 20946834-�� FIFTH FLOOR PAGE !92 <br /> _ r it i n rCuum h'WL b i <br /> i <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATIO,,N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) t <br /> 304 E. Weber, Third Floor, Stockton, G.A., 95202 <br /> (209}458-3449 <br /> NON-REFUNDABLE PERMS EXPIRES i YEAR FROM DATE ISSUER <br /> Licatlan Is hereby made to San Joaquin County for a pennit to construct and/or install lite work described. This apMeaftion is made in wmpliance with Sar, <br /> oaquin County Developinertt Title,Chapter 9-1115,3 and the Standards of San Joaquin County Public Health SarvIms.Environmental Health Divisions' <br /> ILLI-ocstlon 400 N. E1 Dorado Ay2CroesSteetLindsayF City Stockton Z9.95202 P rceg. 907009 <br /> �R.OPERTYowner Joe _Nguyen qad x400 N. ElDorado qty Stocktor>�;p95202 phot 209/941 -8230 <br /> ICantracw VironeX Address 211 0 Adams Ave. a, Mys.F. zip 945-b 70592p�e# 510/568-7676 <br /> ulcartlSubCorrtracwo Orion Env' 1 Address c# Phone*562/988-2755 <br /> iV Coordinates:X ,Y Township T 1 N : Range R 6 E Secttan 2 <br /> IL—AK BE PE F D• <br /> EW W CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) p DESTRUCTION(chaasetype below) <br /> [I SOIL BORING# dila=i2-BORE 1d <br /> n WELL# MW-4 URE GROUT <br /> ' <br /> or: Grout SpeeKoMt>! = <br /> l51G MLWTS: <br /> OF VYiL INSTAL.LA_TIbN TYPE CONSTRUCTION Sp C F ICqQ NS- <br /> ,; <br /> N7-O <br /> iFi1Nt's HOLLOW srEm DIA.OF BOREHOL 6 i MULTIPLE CASINGS? ,(E5 WELL CASING DILL, n; <br /> R(TiZAGT1DN {I AIR HAMMERIDRIVEN CASING THICKNESS 0 , 3�5" TYPE OF CASING: d STEEL VC. OTHER- <br /> [I <br /> "POR 11 MUD ROTARY DEPTH OF GROUT SEAL L 4 � TREMIE TYPE TO BB U D: Q AUGERS U HOSE <br /> z SPARGEusr-I P t GROUT SEAL PUMPED-. p ilea q too (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> S01L BORING p HAND AUGER GROUT SPECIFICATIONS: — e <br /> TF#>=R: OTF+EF2 APPFiDX.BORC]FPiH '' 2 ' OLTED TRAFFIC 6a or []STOVE PIPE <br /> CONDUGTOFi CASING PROP05E�? (ifYF�,listspadflratlons hare} <br /> MI=NTS u <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> d CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. '< <br /> rebyfftem t! have prepared Is ap iication and that t6e..work will be done in accordance with San Joaquin <br /> nn ales and Reg Iations and all applicable California Stats Laws. <br /> ansa r TltdarCompany Kydrogeologist/Orion Environmental <br /> I mmeDrummond Cate <br /> DEPARTMENT USE ONLY <br /> LMAP IN UN.rr IV FILE,ADDRESS: <br /> K PLAN DATED- <br /> Lmflan Acmpled Sy- �._ :.Date Issued—�h <br /> Inspectlan Sy. Date Final Inspectlon By Date <br /> ,struulorr Inapec ori By Date <br /> MF-NTS I COND MONS: <br /> PAM <br /> 1CCOUN7ING ONLY: AID# <br /> ' (}DES FEE IkFo AMOUNT REMITTED CHECK 9 RECD BY DATE PERMITISFRVICE kEQUEST# INVO}CE <br /> OI GI q,W0 I I SIR# 002sa1� . <br /> WC_-WAIVER___ C-57 Getter of Authorization to sign perms I=rtcrtaachment dac 9!27!00 <br />