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12105/2002 15:33 209458:;433 FIFTH FLOOR P".AGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E, Weber;Third Floor Stockton, CA., 95202 <br /> LIP- <br /> (209),468-3"9 <br /> ►ry�, <br /> (209).468-3"9 <br /> NON- EFUNt}ABLE PERMIT EXPIRES 9 YFJ#13 FFtO DATE ISSUED Itcallon is made.in compliance with Sara <br /> Application Is hereby made io San Joaquin County for a permit_to construct andlor Install C0 my described. Thla app <br /> Jo-Aquin courity Develaome`nlTitle,.Chapter 9.119$.3 and the Standards of San Joaquin Caunly Pub/lic_H`pealth Services.Environmental�Health blvi nn. �[ <br /> Ms Street G11y (�`7 IJp Par 1'f �`'Jy� <br /> t, Location, � p�,.. Lirl,,;t <br /> I,WL. <br /> AddressO'��`"-r `1l City <br /> r:C1F;ER'T Owner <br /> zgs.`t.0"Le� <br /> C-5]'Gontrdrlaor � Address <br /> /� + vvL '"C-Lit#Phone# L <br /> Consultant 1 Sub Contractor <br /> GtS Coordinates;X Y <br /> Tawnshlp Range Sectlon <br /> -0 BE PERFORMED: ID DESTRUCTION}{sh3usr�We tele ;l " <br /> ,Iw,f� ,+ELL180RlNG(CPT,GEOPROg£,IiYOROPUNCH.HAND-AUGER.OTHER'1 II QvER-BORE <br /> II SOIL BORING# W-7Oltlf"'_�� II i-PESSURE GROUT <br /> 9vELL#,G{ � <br /> Grout Speeifcallons: <br /> �Oiher: ' <br /> COMMENTS: <br /> T`gL E OF WELL INSTALLATION TYPE CONSTRUCT1ClN�SPECIFICATId S <br /> rr MULTIPLE CASINGS?[]YES ,}310 WELL GA54WG OTA, <br /> FOLLOW STEM DIA OF BOREHOLE <br /> JI',,it,I TORING []STEELC <br /> x _T GTIQN II AIR HAMMEWDRIVEN CASING THICKNESS �� R � TREE ENTYPE OBE USED: .UGEpS tl 3051< <br /> *L,R Q MUD ROTARY DEPTH OF GROUTS <br /> - •.-, . <br /> GROUT SF_AL.PUMPED: o Yes KNO (NOTE: MAX,LMUM FREE-FALL DEPTH I I� <br /> p"i�f�SPARGE Il PUSH POINT 112"Lov C <br /> CI SOIL BORrNG Q HAND AUGER GROUT SPECIFICATIONS. <br /> a OTHEH:��II <br /> OTHER_ APPROX,BOF2ING DEPTHD " OLTED TRAFFIC BOX or R S-ra-IE PIPE <br /> CONDUCTOR CASING PROPOSED? (if Y1=5,listspetarications Yvere;: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIOKS- <br /> I hereby certify that l have prepared this applicationnd tchat�lthe work will be clone in e Calif orn a State Laws. accordance with bars � ar�tstn <br /> I_"Cyt�nty Qrdi s,Ru and Regulations,and all pp <br /> TtlelCompany <br /> Dale <br /> PrintNarne DEpARTMEhI I USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �P�d <br /> ;'Yf:}RK PLAN DATED: <br /> - Date issued <br /> App cAI:Ion Accepted By Final I�speclion By' - pate--- <br /> Grout bzspeclion Sy Dale <br /> bate Ilor <br /> I7estrur-tion Inspection By <br /> ' - <br /> COIU6MRNTS l CONDITIONS: <br /> NTING ONLY: AJD1f <br /> liEG'D SY DATE <br /> PERMIT I SERVICE REauF-s �k 1?v E <br /> i'`„o l:iDES FEE INFO AMOUNT REMITTED <br /> CHECKS <br /> C-57 WG_WAz"ER� G-57 Letter of Autharizatian to sign permit�Encroachment doc if <br /> �Z <br /> � �# , <br />