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1171014tJ V.L iJ J( GU 34 QQ.)4JJ r A r 1r1 rL-LJLJf� rHl]G GL <br /> 89/,13/2001 10 26 20946934'3a FIFTH FLOOR Nu t: ox <br /> WELL PERMIT APPLICATION FORM SITE <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS.=HD) UNIT IV <br /> 304 E-Weber, Third Floor, Stockton, CA, 9 i2O2 <br /> (209) 468-3449 <br /> NOH-REFUNDABLE PERMIT EJ(PIRES 1 YE FROMDATE I SUED <br /> kPpllcalron is hereby made to San Joaquin County for a permit to construct and/or Install the work desalted Is appacabon is made in oomptiance with San <br /> Joaquin County Development Ttte,Chapter 91115.3 and the Standards of San Joaquin County Public I-leatth ermcm,Enwonmental Healy+DivisionAssessors O <br /> BELL Locatlon r ct 2 Cross Sheet W 14ne fOn�V aty SIs Fo Zip S' f 0 Psrwj <br /> >17b 2Aao Crb.wla✓� ca M I Z, S83 honed �?.S:Z77-Z�S <br />'RflPERTYOwner TOS(O Mafj=t�+� "Ca +erre AdOress pewlav D�� <br />:-67 Contractor V+61I 1i ot Diidess leo Ej& CiIyTS It�tr,, lap Llcn j?�" Pl,anin !b- ?�- an <br />.onsultant 1 SuD Contractor fn f lu _ Cy PhonexeL , SD-SSD 19$57 <br /> 3IS Coordrna temY Townshl Range Section <br /> dol Obltaer: f, o;i y .Sc�#lr Ham + fw-- )(If,:+st,31d�l3,sal� ��►� , wa glass (its zsr* ObS9 <br /> RKTO BE PERFORMED <br /> NEW WELL/BORING(CPT,GEOPROBB,HYOROPUNCH,HAND.JW GER.OTHER-) 13 DESTRUCTION(choose type below) <br /> 1]SOIL_BORING 0 p OVERZORE <br /> wELL sI rnI"J- I r»trs1. 1VI W- _-- p PR1=SSURE GROUT <br />'Other, ____Grout Spep6caCorrs <br />'OMMENTS• <br /> rVPE OF WIELL INSTALLATION TYPE CONSTRUCTION SPECIF7 ATIO S <br /> MONITORING OLLOW STEM DIA OF SOREHDLEG7��1�MULTIPLE CASING ?0 YES NO WELL CASING D(A-SQ <br />]#CTION 0 RIVAIR HAMMIERIDEN CASINGTHICKNESS `1D TYPE OF CAST G: OSTeiL. XPVC 1]OTHER] 0 MUD ROTARY DEPTH OF QROUT SEAL5 - * TREMIE E TO 6E USED. D AUGSI:S AHOSE <br /> ARGE p PUSH POINT GROUT SEAL PUMPED, Yes 0 No {NOTE: MAXIMUM FREE-FALL DE IS 301 <br />]SOIL aMNG 0 HAND AUGEP GROUT SPECIFICATIONS Ce <br />]OTHER 13 OTHER APPROX BORING DEPTH ��/ Eng LTI=D TRAFFIC BOX or []STOVEPIPE <br /> CONDUCTdR CASING PROPOSED?6 (1t ES.GSt speafcations here)• <br /> COMMIrNTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCIRCACHMENT PERMITS. <br /> CALLTHE UNIT 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR 1-REQUIRED INSPECTIONS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San.Ioaqu in <br />,ounty Ordinances,Rules'and Regulations,and all appiicable California State Laws. <br /> agneq x ,��T _7dIelCompany S P.� r+IN1 <br />'nntName Skm h91-4!:KD to <br /> DEPARTMENT USE ONLYy <br />'r1TE MAP IN UNIT IV FILE,ADDRESS-. <br /> YORK PLAN DATED: <br /> rppl,cotlon Acceprad By Date Issued !l b t Area LrOP r <br />,rout Inspection I3y Date Final lnspecVon By Dat". <br /> 1e&truccion Inspection By Date <br />:OMMENTS i CONDMIONS,�.�._..-._.,....,, <br /> NT1NG ONLY, A IDX <br /> PE CODES 1 FEE INFO AMOUNT REMITTED CHECK RECD BY DAYS PE MIT/SERVICE;REQUESTto urV010E <br /> 7 WC -WAIVER C-57 Letter of Authorization to stgn parmtt rneroachrnent doc 9/27/00 <br /> i <br />