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18/25/2002 16-36 2094683433 FIFTH FLOOR PAGE 04 <br /> Y ~ <br /> L N'�I€�O�oMIN PAL <br /> HE `WELL PERMIT APPLICATION FORM SITE <br /> KNIT SERVIC6N JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 03 AUG 22 PM 3'- 3]ENVIRONMENTAL, HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E_ Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468••3449 <br /> NO �EFUNnABLE PERArtIT EXPR 1 YFMI <br /> ApplF D11A DATE ISSUED <br /> �cadan 18 hereby rnsde to San Joaquin County for a permit to aanstruct and/or install the work described This application m made in Gompilan*e with San <br /> Joaquin County Development Title,Chapter 9-1115 S and the Standards of San Joaquin County Public Hdalth Services,Environmental Health Division <br /> WELL Location ?50 <br /> t✓ESr f s l ty Srve&7:,,- AssessoParch# r's <br /> 4r�CS�— <br /> PROPERTY Owner �'y Address rf2S�I, '-✓I- City k <br /> r► .P g524 Phone# <br /> e Cw57 Contrac6or6W_,!N y r hr411 Address. <br /> City�r .s� zip 4453 L�c#65�i1o7 Phone# 9eS 313-58e5� <br /> cetnsultant/Sub Contractor. �NiGaRasr ` � 'drew /e/ .�I.4�PIt `hip Ci <br /> $+S 1Fd LIc# 7 Z t I' yPhvInnane#1 6 S45 rf37l GIS Coordinates X ,Y Townsh! <br /> R Range Section <br /> K TO BE PE ORt4IED• <br /> EW WELL/BORINGJK <br /> EOPROBE UN HAND-AUGER.OTHER") <br /> p SOIL BORING# � d DESTRUCTION(choose type below) <br /> [l WELL# ' Q OVER-BORE <br /> "Other: 3peaficadans q PRESSURE GROUT <br /> 13=11 OF WELL,_ INSTALLATION TYPE CQNSTRUCTION SPECIFICATIONS <br /> Q I4MI7170RING 0 HOLLOW STEM DEA OF BOREHOLE fir. MULTIPLE CASINGS? YES ` <br /> CTION W10 WELL CASING DIA�r <br /> Q AIR HAMMER/DRJVEN CASING THICKNESS �� TYPE OF CASING IISTEEL Q PVC Q OTHER <br /> U MUD ROTARY DEPTH OF GROUT SEAL72yTA,- Pffif. mr=m E TYPE TO BE USED p AUGERS OSE <br /> iiiiiiiff-AIR SPARGExn'D <br /> H POINT GROUT SEAL PUMPED Yes [I No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> SOIL BORING AUGER GROUT SPECIFICATIONS .L67N� .+�y� 6r <br /> jtv <br /> jw-HEP-!Lp <br /> OTHE f Il APPROX BORING DEPTH pb _ R� <br /> "' D BOLTED TRAFFIC BOX-or Q STOVI=PIPE <br /> ''CGMMENITS. <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here)- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL.THE UNIT IV INSPECTOR 43 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS, <br /> thereby certify that I have prepared this application and that the work Will be done in accords <br /> ounty Or ce Ru sand Regulations, and all applicable California State Laws. rice With San Joaquin <br /> x Title/Company G v►fit <br /> nt Warne �o~v Date $ d3 <br /> DEPART ENT USE ONLY <br /> LITE MAP 1N UNIT IV PILE, ADDRESS: 3250-- ML <br /> WORT(PLAN DATED. —May 23 <br /> Lication Accepted By <br /> p y Dat*Issuer D Area- <br /> on <br /> c3raut Inspection l3 _Date Final Inspectron By sato <br /> slruotton Inspection By Hate ^-. <br /> ENTS/C4NDrrtpN5 '�- <br /> NTING ONLY, AID# <br /> E CODES FEE INFO AMOUNT RlEMfTTED CHECK# RECID I3Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> sq. 00 Da 3s00A <br /> 57 WC --WAIVER C-57 Letter of Authorization to sign permit Encraachrnent doc <br /> 9lZ7/00 <br />