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09/25%2000 14: 35 20946E3e- FIFTH FLOOR <br /> WELL PERMIT APPLICATION FORM SITE <br /> JAN 1 9 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIH0NIVWN MENTAL HEALTH DIVISION (PHS•EHD) UNIT IV <br /> PERMITiSERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> plication is hereby made to San Joaquin County for a permit to construct and/or install the work desonbed. This application is made In compliance .v:n. San <br /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> ELL Locotion1� 16 W S c I,, �- I;d Cross StreetAssesso,'s <br /> Ciy ret zip S3 Parcel# 2.od- ZYO-221 <br /> :OPERTY O«ner©Wlen4- &-o 1-W'- r Address lY'+00 W -SkL%�tk Cit`y1Trz,, zip°IS3q(Pnonex2oq-?,36-?,3L <br /> 57 Contractor:f&c.�Y'I.uw, Address 236f-Wt�.Us.wv Or City S}.� �v�z 1 /L�SIZz6PnoneZ 2>1- 465 <br /> nsultant r Sub Contractor l O 1�e,y-14 s so�- Address 1,60 uv A.1c.0 A i Q...k�w0i Phonett S-I O - <br /> h ctt 2 39-90 oP <br /> S Co, r inZtes_X .Y _ Jownshlp .Range Section <br /> )RK TO BE PERFORMED- Y`\ <br /> aEW WELL/BORING(CPT.GEOPROBE.HYCROPUNCN,HAND-AUGER.OTHER-) p.DESTRUCTION(choose type koe) O <br /> 0 SOIL BORING ti VER-15 <br /> thef. 0 WELL# tl PRESSURE GROUT <br /> GROUT SPECIFICATION c'AJPco-1- <br /> WMENTS: <br /> RE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 40NITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> .XTRACTICN 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: o STEEL o PVC 0 OTHERS (, <br /> 'APOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS DOSE <br /> .IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,OIL BORING 0 HAND AUGER GROUT SPECIFICATION ((�� <br /> )THER: a OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE FIPE _\ <br /> CONDUCTOR CASING PP.OPOS=D? (if VES.list Specifications here) \^y(1 <br /> )MMENTS: �A:1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS h1 <br /> ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C <br /> unty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. - <br /> ' GAL T E UNIT ly[JN�pECTOR 48 WORKING HOURS INnADVANCE <br /> •FOR ALL REQUIRED <br /> IINSPECTIONS <br /> II / Title/Company. ('(bst�)'I-lo-�7 i / fro �d.t ryt sau.�� Z c. <br /> Name kayt, lge9 bvv'—o-kc's Date k/I 91 �O t <br /> 31TE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> �iication Accepted By Date Issued Z �J' Area <br /> it Inspection By ' , ....o Date z Final Inspection By Date <br /> .truction Inspection By /1 Date <br /> MMENTS r CONDITIONS: NA JAn . A j r^ :� fir, 1, r )g 0 �,9 Ir �--Z <br /> b t1..- �L -LCl+.�� W <br /> COUNTING ONLY, AID4 <br /> .CODES tf <br /> AMOUNT REMITTED CHECK# ]RjEC'DY DATE PERMIT/SERVICE REQUEST tt INVOICOo � I z30/ 0 S O <br /> '-57_ WC/WAIVER C-571 otter of <br />