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06/03/2600 11: 16 w6?4683433 FIFTH F_00F PAGE 6'I <br /> WELL—W-RMIT APPLICATION y <br /> �A tU� Ft7 ,k SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS 'EHD UNIT IV <br />` 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> I. NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM_DATE ISSUED <br /> :pli=tion is hereby made to San Juacuin County for a permit to o:nstruct andfor install Lhe work dasCribecf- Trois Zpplica^art is mzde;n comof an-m wfe,'i S2:-I <br /> :acOn Ccunty Development Title.Chapter S-1115.3 Ona the Standards of Ssn Je�quin Caur,ry Puelic HealthSe-vic_s,En'.^ronmsntal 1-3eaitt�Oivision, <br /> t!L ocation(p C-4 <br /> Sk � _AA5-a255C�5 <br /> Zip 31 Pa,ce!Y <br /> � � as <br /> RCPF-R-ryCwner A6e-e=- - ,• City C Zip�Phone 5s—-1c)7 I <br /> Ltcpk rm--k a-)x p Oh <br /> -57 Contractor�Q��'1�'- vm'. c Address nL7i t W;�m bit, <br /> arisultant/Sub Contractor�(iC��n� oi fonpteJ% 'i <br /> f2��. Io City Tr�CLc; �?hone=_ <br /> IS Ccordinatas_X Y Township Range 5ecron <br /> 'ORK TO 3E PERFORMED: <br /> NZW WELL:BORING(CRT.GEOPRCEIE. HYDROPUNCH,HA.'40-AUGER, OT,HER`; �.G�RUCTIQfV(ctiocse Fa helo.v) <br /> j]SOIL 3DR}NG M 0VSPP'-8CR= <br /> Q <br /> WELL# .[1 GROUT- PRESSURE GROUT <br /> SFECiPiCATiON T'' <br /> OMiMENT w <br /> CPE OF VVE L fNSTALLAT10M TY 'e C014STRUCTION 2PECIF5CAT1o:rS <br /> C1A YITORING ) HCLLOW STc-kl D:A.CF SOPIS-?OLE biULT!PL?CASINGS? ij YES ONO 'NELL CASING DIA: <br /> E CTnA^'ICN Q AIR HA VERICRIV=`: GASN.G THICKNE55 [j STEt'L O PVC 'D OTHER: <br /> 'AFOR MUD ROTARY DE?TH OF GROUT SEAL T RENflr=TYPE 7 SE U:SE7: U AUGERS nLtOSc <br /> R SPARGE 0=USP P`IN T GROUT SEAL FUMPEC: q Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> „OIL EORiNG [3 HAND AUGEP GROUT SPECIFICATION <br /> O T HER: Q c-T-rE:R APPROX.BORING DEPTH U 90L T cam^-AF'r'!C BCX or Q STOVE PIPE <br /> C:NDUCTCR CA,SiNC-PQOPCS50? ,�(if YES,list spec:ti d-_-,s here): <br /> Dti',AENTS: lqk)- �"d M W-3 ote- IDU,-tCt..l %/� lG.y�,�tfC �[il�y '�--.l-f. W2/��t��lr' _ "77 3C 1`F�Nf(:C'CC_�.�u-�it>c� A �e <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENdROACHMENT PERMITS <br /> hereby certify that i have prepared this application and that the worm wilt be done in accordance with San Joaquin <br /> ounty Ordinances, State Laws, and Rules and Reguiations of the San Joaquin County. <br /> " CALL THE IT 1V IN FECTOR 48 WORKING HR5 IN ADVANCE FOR ALL REQUIRED INSPECTIO S <br /> Bred TitlJCampary <br /> int Nary_ Date_ <br /> SIZE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Splic4oti Accepted By L D2te tssued .Area <br /> -.ut Inespectiary 8y _ Date By <br /> :sr_c,icn Inspection By Gate �Y\�'•, <br /> ONI MTE►tTS f CON DMONS: <br /> ACCOUNTING ONLY: A100 <br /> 3c'CODES FEE INFO t AMOUNT RE.LIITTED CHECK� P,EC'A sY I DATE PERMIT/SERVICE REQUEST# INVOICE i <br /> (ot 2 b ? i <br /> C-E7WC/WAVER C-557 Letter of Atithorizaticn to sign permit_.Encroach mer,t dor. 7/27/CC <br />