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02/26;'2004 15:05 2094623433 FIFTH FLOOR <br /> PAGE 01 <br /> v <br /> WELL PERMIT APPLICATION FORM SITE <br /> FEB 1 9 2004 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NIT <br /> IATION <br /> U <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) NITlV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERNIMSERACES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .pplicadon is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> :iaquln County Development TiUe,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ` Assessors <br /> /ELLLoc3tion 5aa9 6A ST L 01.115 At)§,AJ1AE, Cros9 Street a t zZ Jl�� ST_City Lf►TH 1�0l� Zip '.26 Parcel# <br /> ROPERTY Owner 1i�jAt �plzTri/1 E$c Address 8611+ADI5DvrJ- l-D J3pk 799 City-jo&6,Dn1014 Zip J Phone# <br /> -57 Contractor 1/uP W -P l-- .I NJ1kdclmss p0O4fL CitSL ,. Z; 9� 720 � Phone � 7-#1-0,1 E5 � s <br /> onsuttant/Sub Contractor EAOTN-'(fX�Address ��F?J4/l)KLt,/ C Ity f2�[J�7D+JLic# Phone#&.6�92.34^0519 <br /> iIS Coordinates:X Range, Township— Section <br /> /OF <br /> K TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER`) Z ESTRUCTION(choose type below) <br /> 11 SOIL BORING;r 0 OAR-FORE <br /> DWELL;. +Q�RESSUREGROUT <br /> Dther: Grout Specifications: <br /> _OMMENTS: Two On/JTDItJ.Ix, <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> /MONITORING HOLLOW STEM -DIA.OF BOREHOLE` " MULTIPLE CASINGS? 0 YES XNO WELL CASING OIA: Z•� <br /> EXTRACTION 0 AIR HAIAMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC Q OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 52!?� .TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL, DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: < 5 �� �E�sl7D.Cfy1� ! per •�JZ1F CEis�El#T <br /> OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r �^ CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 30MMENTS !— � OT /L'((�W1Tii7L1.tUC4 t.� l-1-S �� 1t7��/ 1JPL� �L>LxGI.N <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION& <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinapees, Rules and ul tions, and all applicable California State Laws. <br /> igned x Title/Company 's TJ� <br /> rint Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> YORK PLAN DATED_ <br /> pplication Accepted By <br /> Date Issued C;L Area Dy I/ <br /> Oate <br /> rout Inspection By Date Final Inspection By <br /> estruction Inspection By Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK;; REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350a. �10 4 (100 Co -3 3? 0 � <br /> 9/27/00 <br /> :=57 We -�R EC E I V E D T I MEc-:FEB, 26, :r 2 ; 5 8 PMorization to sign permit Encroachment doc <br />