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05/03/2001 09: 52 2094683433 FIFTH FLOOR "AGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E, Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PI~RMIT EXPtItt M I YEAR FROM DATE NAUED <br /> plication is hereby made to San Joaquin County for a permit to oonstruct andlor Install the workdeseiibed, This application Is made in compliance Mich San <br /> a^uin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Pubft Health Services,Env*mnenW Heakh Division. <br /> E - Location 54i2 ROTk 1^U , Cross StreNs� M AY("s. Assessors <br /> �. I K 1al cny LA1T 1,•}>?.o� Zipq,_�Paroel�k 196o3no� <br /> tOPERTYOw-(n�erM0k1EkUFU-nL�� Address.�4�—F C�C� City LATI+?,Dp Zip3533DPhone#(° I� 9S9 - 14-7_ <br /> t Contractorf�,PCl�lQn{t��'lrrJ�?It�I�(� Address 2 tC/xy x1�mc(� Zip uo�lt+�3f�8�p►wnaf�510 a37— t}54� <br /> msultant I Sub Contractor RMU-111 CO AVJC[1 Address 16115 VQN t�At Qn e.{q _Li rr,one q' 1 lab0-ID�'0 <br /> :oordinates:X Y .Township Range Section <br /> Lje% K TO BE PERFORMED: <br /> NEW WELL I BORING(GPT IHYDROPUNCK HAN R,OTHER-) 0 DESTRUCTION(&!Doss type below) <br /> IL BORING 0 MD A,L Of [I OVER-BORE <br /> WELL V 11 PRESSURE GROUT <br /> I r. Grout Spacifkaations. <br /> OMMENTS: TMAL DF i <br /> CAF WELL II WTALLATION TYPE GONNTIMIGTION SPECfF,IGMIONG C I Cpm ro ' <br /> ._._NITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?E1 YES [I NO WELL CASING DIA.- <br /> EXTRACTION <br /> IA:EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D 3TEEL a PVC I)OTHER: <br /> OR 0 MUD ROTARY DgPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [)AUGERS D HOSE <br /> SPARGE p PUSH POINT GROUT SEAL PUMPED: p Yes p No {NOTE: MAMMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> HER: p OTHER APPROX.BORING DEPTH 0 BOLTEDTRAFFIC 13QX or IJ STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifica ionis hero): <br /> MENTS. <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 /> t .'eby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> ;i Inty O nances, Rules and Regulations, and aR applicahqle alifomla S to aws <br /> c1r>Lti°C tS#A'1 SmP � <br /> ipned x MUNT For- M0131EP kir- Til Titielcompany <br /> r NameSn toldu> __ Date + �7 O <br /> DEPARTMENT USE ONLY <br /> l' MAP IN UNIT IV FILE,ADD ESS: <br /> OwRK PLAN DATED: 3a <br /> F cation Accepted 13y _7 lZDate Issued <br /> ,1--t Inspection By__� Date Final InsWcbon By Date <br /> estruction Inspection By Date <br /> JIMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> F CODES FEE INFO AMOUNT REMITTED CHECK#4; �RECIDIBYATE PERMIT[SERVICE REQUEST 0 INVOICE <br /> 7 WC=WAIVER_ C-57 Letter of Authorizati n to sign p rmit_ Encroachment doc_ 9/27/00 <br />