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02/1912002 16:12 2094683, FIFTI FLOOR in <br /> PAGE 02 <br /> WELLPERMIT APPLICA ION FORM SITE <br /> MITIGATION <br /> ;. SAN JOAQUIN COUNTYNIT IV <br /> ENVIRONMENTAL HEALTH DEP) RTMENT (EHD) <br /> ` 304 E. Weber, Third Floor, Stock on, CA., 95202 <br /> (209) 468'3449• ❑ <br /> NON-REFUNDABLE PERMIT EXPMS 1 YEAR FROM DATE ISSUED <br /> pplieation is hereby made to San Joaquin County for a permit to construct and/or install the ork described. This application is made in oompliance with San <br /> aaquin County Development Title,Chapter 9-1916.3 and the Standards of San Jea uin Cou ty F�vironrnental Health Department. <br /> r� t It Assessors <br /> TELL Location 20C S Kr+o Ln in s1-__C+tiss Street 1- ty Zap Pa <br /> ROPER-TY Owner 0dL1jb'Qyrt..r Address W Ctty 'T 4 Zip So?G Phoneft ,?d' - 9y�-7$T•3 <br /> •57 Contractor e 7 AddressSa,r�i�D S 1- city r rdZip Licli�i3�O387Phone#510-J37-3/575 <br /> :onsultant 1 Sub Contractor Address c City cto�t _�Ic#1 Phone# 4�� p? 360 <br /> ;IS Coordinates;X .Y Township Range Section <br /> vp RK TO l3E PERFORMED: <br /> NEW WELL/BORING(CM,G1]DESTRUCTION(choose type below) <br /> 0PR08E,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> "OIL BORING# A( Q OVER-BORE <br /> p WELL# 0 PRESSURE GROUT <br /> Other: Grout 5pecifi tions: <br /> :OMMENTS: <br /> WE OF WELL INSIAI.LATIQN TYPE CONSTRUCTION SPECIFICATION <br /> I MONITORING 13 HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?17 YES AAO WELL CASING DIA: <br /> i EXTRACTION j AIR HAMMERIDRIVEN CASING THICKNESS It TYPE OF CASING: O STEEL 84VC []OTHER: <br /> I VAPOR p MUD ROTARY DE:p-m OF GROUT SEAL TREMIE TYPE TO BE USED: q AUGERS a HOSE <br /> I Alii SPARGS PUSH POINT GROUT SEAL PUMPED: q Yes lNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOL BORING 13 HAND AUGER GROUT SPECIFICATIONS; <br /> I OTHER: ERAPPFiOX BORING pEi'TH q BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here); <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 certify that I have prepared this application and that the wor k will be done in accordance with San Joaquin <br /> ',ounty Ordinances,Rules and Regulations,and all applicable Califo is State Laws. <br /> to iigned:r `�io AA:n= _ Ti )tle/Company �d . <br /> 'tint Name Date 5 -3•eoZ _-- <br /> DEPARTMENT USE ONLY <br /> HTE MAP IN UNIT IV FILE,ADDRESS: ZCU-5 T7-4c U«. <br /> YORK PLAN DATED: 46 — O Zr <br /> application Accepted By Hate Issued 5' Z Area <br /> ;rout Inspection 6 Date Final Inspection By Date, --- <br /> testruction Inspection By Date <br /> :OMMENTS 1 CONDrhONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REmrrlrED CHECK# t <br /> BY ATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> Vol1! s 007111 t 3 <br /> .-57 WC -WAIVED,,•-.,.,' C-57 Letter of Authorization to si n permit V Encroachment dot 1125/02 <br />