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MAR-12-2002 12:19 EST YOST 530 756 5991 P.03/04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 �4 � ' e3' z 5 <br /> NON-6.1 UNI)ASLE PERMIT EXPIF QE YEAR FROM DATE 1SSUISD <br /> ApgliCation is hereby made to San Joaquin county for a permit to wristruct and/or in=ll the work descridod. This applioatipn Is made in Compliance with San <br /> Joaquin reunlu Develnorlmerit YiUe.Chapter$-1175.3 and the Standards f Sp an Jaaqui�Cqunty�nvtranme i�Flealth Department lj�� <br /> ��1 � ( I�-.� r - \ Asses so?sa.�7�^ 1:96 <br /> WELL Location _ 1 Cross Street -- City 7iPj ParceiSY_l• <br /> PROPERTY Owner l O� f <br /> Addreea City, ip - _ Phone# _ <br /> C-57 Contractor ST ~Address iy c e rd a�81� $ i� S3Y 4 onem 43 JA _ <br /> 19041 <br /> STS ,. tb <br /> Consultant I sub Contractor /,Jt _Q 104Addra;6 I.Z C.D a.l� d i►y � L;q� Phone# S30���i�.7<� <br /> g e� s Iwo <br /> Csl$Caordinmtes:X , Tawnship _ _Fynga� SecliCn <br /> WQI?K TO 8F PERFORMMr <br /> 11 NEW WELL/SOR NO(CPT,GEOPROaE,HYDROPUINCH,HAND-AUGER,OTHER-) � )EMUCT1ON(choose type below) <br /> 1]SOIL HORIN 4 �� II OVER SORE <br /> 1 1]WELL ri Co <br /> r. / , PRESSURE GROUT <br /> "Other- <br /> COMMENTS: i� Grout Specification.-:2 2 W `�►/ _ <br /> PE Or.WELL tNS ALL rloN rYPE <br /> a MONITORING AHOLLOW STEM DIA.OF SOREHOLS MULTIPLE CASINGV(]YES.:JNO WELL CASING DIA.: � � <br /> 11 EXTRACTION 1]AIR HAA1MEFt/DRtVEN CASING THICKNESS TYPE OF CASING: Q STEEL PVC OTHERQ�CI—i 1Jt <br /> Il VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS 0H96E 10'pQ, <br /> p AIR SPAkGE II PUSH POINT GROUT SEAL PUMPED: a Yes V4wo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL 50RING D HANG AUGER GROu7 SPECIFICATIONS: Q?.yJou,h t4-@„ <br /> r\ <br /> 'OTHER: a OTH5_R APPROX.BORING DEPTH a-UD 11 BOLTED TRAFFIC BOX or 13 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED,) (if YES,list speciGcat ons <br /> *COMMENTS: V) <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that 1 have prepared,this aDolication and that the work will be done in accordance with San Joaquin <br /> County brrdinanc , les a egulations,and all applicable r Laws. <br /> Signed TiYla::;mG'..r}• . t... / 1 OJJ�a�I`. <br /> r <br /> Print N me Date 3— 1.Z. 07t, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' n p <br /> Applioatian Accepted By Data Issued /�' D Z <br /> Area�AU-."0Cj-S <br /> Grout lnap2ctian$Y Data Final!ns - <br /> pection By Date__ <br /> Destruction Inspection By /y Qate <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> enPMy <br /> PE CODES Ftp INFO A>ut4UNT REMITTED CHECK u REC10 BY DATE PERMIT I SERVICE REQUEST S INVOICE <br /> �5 o2- �o- 6�0 L �z pz- sR# Do 7 4 <br /> G57 WG _-WA21IERC-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br /> MAR-04-2H02 14;22 2094583433 97% <br /> P.02 <br />