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..-197113/2001 08:36 94683433 FIFTH FLOOR PAGE 02 <br /> + <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION. <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION {PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA.,85202 <br /> (209)468-3440 <br /> D FUNDABLE P R EEXPI E OM E U <br /> Appllcatian Is hereby made to San Joaquin County IEW <br /> for a permit to Construct and/or Instail the W OM described. This 8ppll�tion Is made In oCntpilence vrfth San <br /> Joaquin County Development Titte,Chapter 9-11104 and the Standards of San Joaquin County Public Health Services,Environmental Health DIValon. <br /> WELL Locsflan Jt+ t I+ t <br /> �t 141- Cross Street City`� It zip Parcell ads <br /> PROPERTY Owner [ Wa -- <br /> { dress Ciiy--�,._..�p Phone# <br /> 0.57 Contraatorf�y a VWVAI <br /> ConsuRaat I Sub Cont-acwr I <br /> dres8 �ayr1 1[ a Clly. a��LE <br /> 3III Coordinates: Townships. Ra e <br /> n9 $BCtio <br /> EF MEPA <br /> EW WIMI-/SORING(CPT,QEOPRO89,NMROPUNCH.HAND,At.IGER,OTHER•) 0 <br /> ' I]SOIL BORING# DESTRUCTION(Clhoose type below) <br /> '1]W%.!4# D OVER-BORE <br /> .—Grout cdfleat' n PR!: URE GROUT <br /> ;OMMENTS. �% sa io s:1'Qz,�Pa1t�W"I k c UNJ !r 1-2- r' � ,.4,r� ►.� <br /> O L INSTAL aN 7YPE `'`C N it 10 6 C CA dN5 <br /> MONITORINGHOLLOW STEM (1;;3'we i DIA.OF BOREHOL MULTIPLE ,� <br /> CASING$?Q YES �IO WELLCA13lNQ DIA. Z <br /> I FACTION VAJR HAMMMI)RIVEN CASING THICKNESS TYPE OF CASING: Q STEEL fffVC Q OTHER. <br /> I VAPOR IUD ROTARY 1`�& DEPTH OF GROUT <br /> SEATREAIRSPARGE well MIE TYPE TO BE USED: <br /> 11AUGERS' WHOSE <br /> GROUT SEAL PUMPED: ]'Yes' p No (NOTE,MAXIMUM FREE-FALL DEPTH IS 30') <br /> r'%84RING Il HAND AUGER GROUrSPECIFICATIONS: <br /> i IER: .,,...0 OTHER APPROX.BORING DEPTHTI4AFFIC 84X or d STOVE PIPE <br /> 7 t1J��� t CONDUCTOR CASING RO r;D?„ _(if YES,fist specifirestlons hsre)• <br /> 'COMMeNTS•�[ N t cv [ Ws u- ro. c SCS w STSVi. r�O DOe-Viz, e�t�, I ,rn+cc,� To tz;a'. <br /> ltr, y,n r' }u� <br /> NOTE: OFPSITI- BORINGS REQUIRE ACCESS 6RENCROACHMENT PERMITS. <br /> j . <br /> CALL THE UNrr IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 herefy that l have <br /> Cprepared this application and that the work will be done in accordance with San Joaquin <br /> oun Ordl antes, Rules an lations,and all applicable CallfOrnla State Laws. �f <br /> gnedx - - rlttetcompany �4 � <br /> / ? 4--// /,� <br /> sNrint Name 1*►t�I i1t1[OL''! — <br /> I <br /> ER SE ONLY Dam <br /> TMENT U7 �e 1 <br /> '_TE MAP IN UNIT IV FILE ADDRESS: f a, �-}— <br /> WORK PLAN DATED: f U p <br /> i <br /> + , <br /> 139cadon Accepted By Date Issued <br /> Grout Inspection BY Datee <br /> Final Inspeotlon By Dots <br /> ,- aWOdon IrtepecHan <br /> Date <br /> 'MMENTS/CONomoNs: <br /> ACCOUN'nN(o ONLY: AID# <br /> 13000B3 t-leEtHFQ AI410t1NTtREMITTE <br /> 0 CHECK# REC'DBY DATE PERMri'/8ERV1dk'1tE4t)g8T ! INVOICE <br /> I1 a m L <br /> .57 W1=-WATER C--57 Letter of Authorization to sign permit Encroachh}ent do <br /> c,_ siz7ioo <br /> r CGS --� <br /> I.LfA 5 1(1 11-9 <br />