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05-18-2881 0?:44AM FROM TO 19166358905 P.e2 <br /> WELL <br /> yPERMIT APPLICATION F�ttM SITE <br />` MAY 2 5 2001 SAN JO�QUIN COUNTY PUBLIC HEALTH.SERVIC S <br /> � MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) IT IV <br /> 3.04 E.!Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> IW0N-'REFUN0ABLE PERMrr EXPIRES 9 YEAR.FRQM DATE ISSUED <br /> Application is hereby made to San Joaquln County;for a permit to construct and/orinstall the work described. This application is made in compliance with San <br /> Joaquin County Develo�`e�Ti le,Cha t r 9-131 ,3 a Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> I b <br /> Assessors <br /> WELL Location ` Toss Street —city Zip Parcel# <br /> PROPERTY Owner. CAy—y : (y V I;�rr-iI Address I1 6 I " Clry d r Zip ` ' Z9D Phone# r <br /> C.67 Contractor G'r D/rll,%tt Address /411Je City Zip �-:3Lic# PhoneRr�S <br /> Consultant ISub Contraetar Address 7-7DI P,-e2ge[�P k19,-City ,c i c *c# Phoned <br /> GIS Coordinates:X Y ,Township Range Section <br /> C WORTS TO BE PE MED: <br /> KNEW WEL O NG CPT,GEOPROBE,HYD PUNCH,HAND-AUGER,OTHER-) Q,DESTRUCTION(choose type below) <br /> ,SOIL BORING#. D—� Fri-L f - 0 OVER-SORE <br /> Il WELL#' 0 PRESSURE GROUT <br /> 'Other, rout Specifications: <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTR TI N S EC FICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF.BOREHOLE MULTIPLE CASINGS? [)YES a NO WELL CASINS DIA: <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE Oi-CASING: 0 STEEL Q PVC p OTHER: <br /> p VAPOR 0 MUD ROTARY QFPTH OF GROUT SEAL TREMIE TYPE TO HE USED. 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE B PUSH POINT GROUTSEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL IDEPTH IS-30) <br /> RZOfL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> B OTHER: 1THER_ G�s�y 66 ,APPROX.BORING DEPTH j]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE; OFFSITE 1300INGS REQUIRE ACCESS OR ENCROACHMENT'PERMITS. <br /> CALL THE UNIT IV INSPECTOR-48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby'certify that I have prepared tois application and that the work will be-done in accordance with San Joaquin <br /> County Ordinanqes, Rules and Regubations, and all applicable California State Laws. (� <br /> Signed TtlefCompany- Q CI'r� ti <br /> Print Name �_ns� _ i7M;!�1(_! .. Date— 2 <br /> DEPAQRTMENT USE ONLYSITE MAP IN UNIT IV FILE,ADDRES .,: E .1) l <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 3 D Area <br /> Grout Inspection BY DatFinal Inspection by Date <br /> Destructionanspection <br /> By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: A!p# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_,,,,, Encroachment cioc� 9/27!00 <br />