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08/25/2083 16 36 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> IVIROlI EIIT#46 MITIGATION <br /> PFPMIT s � QUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 03AUGNVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> G 22 p M 303 x. Weber, Third Floor, Stockton, CA., 95202 <br />' (209) 468-3449 <br /> ON-REFUNDABLE PERMIT EXPIRES 1 YEAH FROM DATE IS.*1315-101 <br /> Application is hereby oracle to San Joaquin County for a permit to 0onstruct andlar install the%vork described This application is made in catripliance with San <br /> Joaquin County riove opment Title,Chapter9-4115 3 and the Standards of San Joaquin County Public Health Sdr+roes,Envinxrmental Health DnAslan <br /> Assessor's <br /> 1 IELL Location 3 �� OOG ��„� Criss Street 'S�City p '1!9z4;8 Parcel# Q$2-crda-Q 4 <br /> PROPERTY Owner&Zk� Qer�Ia r _ _Address U/6-77 fie!!6raedkro _ <br /> It 0ty c ,'Zip g! Phone#C-57Contractor-e.. iIsa. Address 9$4 Qty r� z TaP , Lic#i�a�` Pltonei� 3�5$� <br /> � <br /> Consuttant 1 Sub CantractnrS w_I? rrig>•rww� t Address 26 .Mit-1 ,�, city .. be 72-t 1 Phone#[tL1 SSS-q T <br /> 013 Coordinates X Y Yowmship Range Section � <br /> T(013E ERFORMED• <br /> I W WELL/BORING %,.,L <br /> EOPR09 ROPUNC HAND--AUGER,OTHER- 0 DESTRUCTION choose <br /> BORIN -*I C T—Z ( type below) <br /> p OVER-BORB <br /> 17 WELL# 17 PRESSURE GROUT <br /> Other Grout Specifications <br /> COMMENTS 2 - 2CA <br /> IME0117WELL INSTALLATION Tli PE CONSTRUCnON SPECIFICATIONS <br /> 1}MONITORING 11 HOLLOW STEM DIA OF BOREHOLE 2 " MULTIPLE CASINGS?ll YES $rNO WELL CASING DIA <br /> CTION D AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING 0 STEEL 0 PVC Q QTHER <br /> R <br /> Sj]?MSMD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED pAUGERS 4��OSE <br /> AIR SPARGE POINT GROUT SEAL PUMPED %Ues p No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING II HAND AUGER �^ GROUTSPECIFICATIONS <br /> ER CIP r _ Pq'HE � i APPROX BORING DEPTH !O i_ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 01r=� CONDUCTOR CASING PROPOSED — (d YES,Ilst specificahon9 hnra) <br /> 'COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS_ <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> hereby cern that 1 have prepared this :application and that the work will be done in accordance with San Joaquin <br /> County O Ina c Ri es and Regulations,and all applicable California State Laws. <br /> Igned x rtielCornpany I �. <br /> rant Narno1DOLIV.4:� Date 8—/y D 3 <br /> DEPARTMENT E ONLY <br /> LITE MAP IN UNIT IV FILE,ADDRESS:_ VZ g O W �U err rr,e r LA rt� <br /> WORK PLAN DATED; <br /> Lplicatlan Accepted By Y <br /> L a+ ;a Mfl- dat-+k2eu Data Issued Arca <br /> Grout Inspection By Date--jFinal inspection By.... Date _ <br /> Ctlori Inspactlon By Date <br /> OMMENTS I CONDITIONS: C P <br /> OUNTING ONLY, AID# <br /> PE CODES FER INFO r IL40UNTREMITTI=D CHECK# RE0113 BY DATE PERMIT!SER%nCE REQUEST# INVOICE <br /> 3501 <br /> ��. 6o-Cc <br /> ODES <br /> oa soo © <br /> -57 W._-WAIVER_ C-57 Letter of Authoriznffon to Sign permit Encroachmeht dor- 9127!00 <br />