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02/19/2002 16:12 2094-68343 FIF FLOORPAGE 02 <br /> - WELL PERMIT APPLICATION FORM SITE <br /> SAN J.OAQUIN COUNTYMITIGATION <br /> IV <br /> RONMENTAL HEALTH DEP TMENT (EHD) <br /> 304 E. Weber, Third Floor, Stock on, CA., 95202 <br /> (209) 4683449 <br /> 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> kation is hereby made to San Joaquin County for a permit to construct and/or install the vrork described. This application is made in compliance with San <br /> uy D <br /> in Countevelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> } Assessor's <br /> ELL Location Cross Street Ci Zip PameM <br /> �PERTY Owner Address W Cityf <br /> f Zip SaG Phone# ,70'1- 9;/�-787.3 <br /> S!Contractor Address /�/QO S.a�AiSD�.S�_—clty z zip ) Lic7i =Pnone# <br /> sultant/Sub Contractor Cd <br /> ar ' Address c CityswGra►w+�lkicFk Phone# 9!G- p��-33CD <br /> [Coordinates:X Y ,Tflwnship Range Section • <br /> T t3E PERFORMED: <br /> 1/V WELL!BORING(CPT,G�OPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> OIL BORING# 11 OVER-BORE <br /> �WELL# 0 PRESSURE GROUT <br /> her Grout Specill tions <br /> IA MENTS: <br /> if r:OF WELL JNSTA4ATION TypE CONSTRUCTION SPECIFICATION <br /> NITORING I]HOLLOW STEM DIA.OF BOREHOLE_ M TIPLE CASINGS?]]YES 00 WELL CASING DIA: <br /> �44MON AIR HAMMER/DRIVEN CASING THIGKNESS TYPE OF CASING: []STEEL OVC ©OTHER: <br /> FFFv r-OR ]]MUD ROTARY DLPTH OF GROUT SEAL TREMIE TYPE=TO BE USED: p AUGERS Q HOSE <br /> rR SPARGE a PUSH POINT GROUT SEAL PUMPED_ gYes No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> DL BORING l]HAND AUGER GROUT SPECIFICATIONS: <br /> ..THER ER APPROX.BORING DEPTH J6 BOLTED TRAFFIC BOX or 13 STOVE PIPE <br /> CONDUCTOR CASING PROPOSE ? (If YES,list specifications herer <br /> f—,MMENTS• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PEWITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the war will be done in accordance with San Joaquin <br /> rlty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> I t l CI AZ:iL .f'C%L� _ Tide/Company Fill T - <br /> tPtame Date S 3•�z <br /> DEPARTMENT USE ONLY <br /> .ITE MAP IN UNIT IV FILE,ADDRESS: <br /> F)RK PLAN DATED. <br /> pplication Accepted Ely Date ued Area <br /> r7tst Inspection 6y Date Final Inspection By Date <br /> ). truction Inspection By Date <br /> At' 1 CONDRIONS• <br /> 'XOUNTING ONLY. AID# <br /> PE CODES FEE INFO AMOUNT REMn-TED CHECK# REC'D BY 0 TE PERMIT 1 SERVICE REQUESTS INVOICE <br /> r-- <br /> 289 <br /> ..-57 WC -WAIVER C-57 Letter of AUihoriZotion to si n permit Encroachment doc 1/25/Q2 <br />