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08/03/2000 11:16 2094683433 FIFTH FLOOR PAGE 02 <br /> 1 <br /> WELL �1RMIT APPLICATION FO' SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION � <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> LION-REFUNDABLE PERMIT E-XPiRES 1 YEAR FR61M oATE ISSUED <br /> :='i=tian is:hereby made,o San Joaquin County for a permit to caristsuct andlor install the work Ceseribee. T'1iz a,;ptirztiorr is made Fr.camplizrca with San ' <br /> a,uin County DeveEopmentTEtle.Chapter S-'115.3 and them S•,ardards of San jeaquin C-=rtty F:.lic Health Services,Environmental Health division, <br /> �- <br /> ELL Location Cross Street City Parcels* o <br /> �CPERTYOwr:sr C- O�� Address�� �u/ �it�, City Zip l Pmna�W--M- 64 <br /> 57 Cantractor[�� y,�✓ Address/??1;k`/ lCo F/1f Gi o-�� Zip !.iC�''TPt:one# �e✓'y <br /> insultant i Sup Contracto -117'r- F je-�' —:v-, city z C# Phweft: �-$�-67 <br /> 5 -'Cardinatas:X Y Tawnshi? f3anga Saction <br /> ARK TO SE PERFORMED! <br /> `jEw WELL I BORING(CRT.GE0PR0BE. iYCRCPUNC1i.HANO-AUGER,OTHER'; Af pBSTFiJCTIOiV(Choase type below)❑SOIL BORING r. 11 OVER-SORE. <br /> 0 WELL M OFRES URE GROUT <br /> ther_ IGOUT�P=CIPiCAT l0lF <br /> •-S kAJ .2-o '?65 <br /> "PE OF WE L' INSTAL A_TION TYPE CONSTRUCT1QN SPECIFICATIONS <br /> ORIN Q HOLLOW STEM CM.OF 80keHO F- MULTIPLH CASENGS? II YES ONO. WELL CASING DEA: <br /> 'X"R�CTIOrr {j AIR HA;tir MERIORIVEi i CASING THICKNESS r PC OF CAStNG: 17 sPVC d OTHER: <br /> ?OR nil D ROTARY b1=?Tri O•GROUT SEAL i RF4MIE,TYPE i O el'VSEL)-. U ALIG✓ RS OHO-5c <br /> 5PAFtC= 0 PUSH PCtrrr GROUT SEAL P;11+rPE0: C Yes 0.14o (NOTE: MAXIMUM. FREE-FALL DEPTH 1S-30') <br /> t .c>�9oRIhIC3 p Hr N[-,AUG7ER cRou-SPcCIFiCAM0N <br /> 13 C-r ER APQRCX.BORING DEPTH SQLTEC, I-AAFFlC$CX or E <br /> � [�STOVE PIP_ <br /> 00N3!-TCF CASMG PRbPCS=0? (if YES,fist specifir�tlons herb}: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> eredy certify that I have prepared this applidation and that the work will be done iM accordance with San Joaquir <br /> aunty Ordinanczs, State Laws, and Rules and Regulations of the San Joaquin County. <br /> i <br /> "CALL THE UNrT IV INSPECTOR 48 WORKJNG HRS IN/A�DVANItE FOR ALL REQUIRED INSPECTIONS <br /> _d.S G <br /> it Name <br /> SITE MAP IN UNIT IV FILE A00RESS [WORK PLAN DATED <br /> 0EPRRTW4NT USE ONLY <br /> :17;:3";on:accepted Say Date Issued � Area <br /> -:'-nsRection EY Gate Final'fnsoactrcn By Date <br /> Ckn Insneetlon33y date /C,//ld <br /> 1fMENTS I.CONDrrIONS: � /�w <br /> CCOUNTING ONLY: AIDV e <br /> :ODBB FEE INFO i AMIMUNT REMITTEE) CHEdK ir' R6G'D t3Y DATE P1s14MIT/SEIMCE REQtIE5T I INVOICE <br /> 16 I �z�16 o j <br /> C-�7 WCIWAZVER C-57 Letter of Authorizaticn to sign permit Encroachment doc 7/27/00 <br />