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08/01/2000 09:07 2094683433 FIFTH FLOOR PAGE 02 <br /> o <br /> MSAN <br /> WELL PERMIT APPLICATION FORM SITE <br /> UBLIC HEALTH SERVICES o JOAQUIN COUNTY P '-. D <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 AUG 7 2000 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i3�41W` /,:0WW+r,"th San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> I / cAssessor's <br /> WELL Location 6- ^ "' v /u S � S�Cross Street C�7/ 1G1�,! City pck Zip 52P qParcel# /D V- /bo / <br /> PROPERTY Owner j_)P'h t- kt_ 4 P S� Address ��� �/��'1� /City ZiP�Phone#Q10S-fS_b '23 / <br /> �h v,SP t%�ros Addreh��i /� ��i p� (o�3p honc#20ri <br /> C-57 Contractor _ - z Lie# <br /> 1 <br /> suite S��ntractor� 4 <br /> �SSyG/�' S Address//��2 ��f�NS / C��City G�?h7tet-Vc# Phone#g��-(/W" »t7U <br /> con 02Nb� Range l//a Fc-5t Section <br /> GIS CoordinatesiK��•9��2 5 .x�lo2/ •�� Gi D� ,Township <br /> \WO/RK TO BE PERFORMED: <br /> kKEW WELL BORIN (CPT,�11ILIIINI <br /> Yo}OPUNCH,HAND-AUG'�R`.OTHER-) Q DESTRUCTION(choose type below) <br /> / ` # (y —f[TC l f� y7 Cho 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE__MULTIPLE CASINGS?D YES []NO WELL CASING DIA:-- <br /> U EXTRACTION AIR HAMM ER/D R(VEN CASING THICKNES::_ TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> p AI SPARGE 0 PUSH POINT GROUT SEAL PUMPED: )(Yes Q No (NOTE: MAXIMUM FR E-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGEP. GROUT SPECIFICATION 61 4 -N''QM <br /> � 101+ , X 1'-16 &T Cie( �0/'1 USI/AS <br /> [j OTHER: OTHER f,U ✓ b-C_ APPROX.BORING DEPTH t b -q J 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: 3 `✓D/ h QO�v v�(e �D C7 d7, Sammi. +V o / <br /> NOTE: FSITE BORINGS REQUIRE ACCESt OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> CALL THE-",IT IVI E5TOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x Title/Company ��^'UH vt�j��� <br /> 0 <br /> f- "t Date G U <br /> Print Name <br /> SITE MAP IN UNIT IV FILE DRESS !WORK PLAN DATED <br /> DFPARTMENi Ust ONLY <br /> Application Accepted By <br /> l/ Date Issued ' C Area <br /> Grout Inspect)on By Date Final Inspection By Date <br /> Destruction Inspection By DatA <br /> f7�_ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C" L � / t?� � <br /> 7 - <br /> C-57 WC/WAIVER C-57 Letter of Authorize i6n-�0 l Sri permit Encroachment doc 7/17/00 <br /> G / <br />