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._a2/18/2002 13: 36 20946F '�3 FIFTH FLOOR, PAGE 62 <br /> 15/2962 13:01 2094633433 FIFTH FLOOR PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> NON-REFUN0ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> )pllcation is ha=y made to San Joaquin County for a permit to construct andlar instaa the work desenbed. Tnis appfication Is made in comgance witti San <br /> ;aquin County Development 711110.Chapter 41115.3 and the Snnda�cLSsn Joa'7' County Environ 1 th pepartnenL <br /> �n P I R( r�1 4414 �s �I zI = R.}asseI# <br /> T.lL+ ocalaen •kE u ` 4w I City ZIP Paroal# <br /> ROPERTYpwne ! 5 1~ a rays Sly(tl� - CSty �" /���'Ia SLPhone# / <br /> L-57 ContraCbr '✓� lZ <br /> Address <br /> ernsuttarrt1SubCvntmcto Ic7 x �t address r375 iYtWdr') �-aty�Licr��Pho `1 <br /> 6gCion <br /> IS Ordinates:X Y TawnShip Range_ ,'t t� <br /> fORK TO M PERFORMED: c Q CESTRV Q PION(o mese type bd*-) <br /> NEW WELLI BORING(CPT,GEOPRCBE MYOROPUNC . ND•AUG Tz� 0 OVER•t30FtE <br /> $SOILBORING# id QPR=R-BOR C-ROUT <br /> Q WELD( <br /> 7ther: Grant SpeciScation.:; "- <br /> OMMGNTS: <br /> YPE OF WELL INSTALLATION TYPE CONY7M CTION SPECIPICATIQNS <br /> rvtON1T0RING HOLLOW STw DIA QF BOREiiOI E�/-�-MUL'MPLE CASINGS?Q YES XNO WELL CASING OIA: <br /> yTRACTI[)N Q AIR HAMME�RIVEN CASING TH VOJESS T'(PE OF CASING= (l STEEL Q PVC Q OTFiI"R <br /> VAPOR_ Q MUD ROTARY DEPTH OF GROUT SIAL�w �� _T �►1tE TYRE TO BE=USEI]: �AUGERS NOSE <br /> AjR SPARGE PUSH POINT GROUT SEAL PUMPED: Eyes fl (NOTE: M MAXIMUM FRE ALL EPTH 3�') <br /> SOIL SOMNG HPND AUG>✓R GROUT SPECIFICATlON9: BOLTED IC BOX or U STOVE PJPE 1 <br /> OTHER:_ —D OThfER ' APpRO?C BORING DEPTH (i- <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications heraY <br /> 'OMMENTS: <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 diet the work will.1be done in accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> TdlefComp <br /> igned �- <br /> rnt Name <br /> � - •�A oatr � O <br /> J D&ARTMENT USE ONLY <br /> .ITE MAP IN UNIT N F1L�ADDRESS= <br /> YORK PLAN DATED: �� <br /> ppl;cat;on Acceded By_ !l L ._ Oahe Issued /�!� Area F <br /> Date Fnal Inspection ByDate <br /> mut Inspection Bys_ <br /> eshucton In,SDOCUOn BY Date <br /> 'OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# sere <br /> PE CODES FEEINFO ANIaUtIrREMTITfD CHECK if RECD BY DATE PERMIT I SERWCE REQUEST WWICS <br /> �=95"0 7 x/07 G/•¢oz_ Re Qo7Oac ! <br /> -57 WC WAIVER_ G57 Letter of Authorization to sign permit_Encroachment doc_ V25102 <br />