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i F 1 J.L IAP 060- I UL
<br /> WELL PERMIT APPLICATION FORM SITE
<br /> l MITIGATION
<br /> SAN JO QUNITUIN COUNTY PUBLIC HEALTH SERVICES IV
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<br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)
<br /> 304 E.1 Weber, Third Floor, Stockton, CA., 95202
<br /> (209) 468-3449
<br /> NON-'R.t"FUNnABLE PERMIT EXPIRt;S 1 YEAR,F-RQM DATE ISSUED
<br /> i ppRcabon is hereby made to San Joaquln County,tdr a permit to construct andlor install the wor1C described.-This application is made in compliance with San
<br /> Jaaqu3n County Develjp�ri 5�C,, ter 911�3 nd the Standards of San Joaquin County Public Health Services.Envlronmental Health Dlvislon.
<br /> jjAssessors
<br /> WELL Location Cross Straet City -Zrp Parcel#
<br /> PROPERTY Owner My-. [err� Ir�rclit; addr�gs t tZ (�• lit�l�!x_��y Clty- �,,J; _ Zia y5";-WOPhone# '
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<br /> C7 Contractor Gred�i ��r;�jr ,f Adl1ress ` /��Q City *i�?eZ Zip` 75+ U,4Phone#(//Z-
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<br /> Consultant/Sub Contractor rU �� d .�r'viae Address Z.761r�Prk prCity&ac j�c��g%c#f Phoneft
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<br /> GIS Coordinates:X 'y Township Range Saction
<br /> WORK TO BE PERFORMED,
<br /> VN EW WEL O NG CPT,GEOPR06E,HYD PUNCH,HAND-AUGER,OTHER-) • [1 DESTRUCTIC)N(choose type below)
<br /> .SOIL BORING#! - t3-3 a OVER-BORE
<br /> 0 WELL# []PRL-SSURE GROUT
<br /> 'Other: rt Gtout Specifications:
<br /> COMMENTS:
<br /> TYPE OF WELL INSTALLATION TYPE CON$TRQQTIQ N EC FlCAT10NS
<br /> II MONITORING 0 HOLLOW STEM � DIA.OF BOREHOLEMULTIPLE CASINGS? YES 6 NO WELL CASING DIA-
<br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN. CASING THICKNESS _ _ _ ._TYPE OF CASING: 0 STEEL 0 PVC []OTHER:
<br /> B VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USE'0: U AUGERS [j HOSE
<br /> aAIR SPARGE j]PUSH POINT GROUT SEAL PUMPED: 0 lies a No (NO-TE: MAXIMUM FREE-FALL DEPTH IS 301)
<br /> ,aZOli-BORING U HAND AUGER GROUT SPECIFICATIONS:
<br /> 0 OTHER: THER 1)- %C1-/-1'` A1,r�APPROX.BORING DEPTH 0 BOLTED TRAFF4C BOX or 0 5TOVE PIPE
<br /> CONDUCTOR CASING PROPOSE07 (if YES,list specifications here):
<br /> 'COMMENTS:
<br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT'PERMITS-
<br /> CALL THE KNIT IV INSPECT .R 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.
<br /> 1 hereby certify that I have prepared t�is application and that the work will be-done in accordance with San Joaquin
<br /> Gouty Ordinanrzes, Rules and Reraulatinnr._ nnel ul1 a ,r��..-.t,�.,r. Fzx __•_ ..._. _
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<br /> =i#'65Rte♦ •-,.:�aflin. =941x...a. "T-02::uk7X$r- .d.�ra:,Cp'rsh' W..
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<br /> BROWN AND CALDWELL UNION BANK OF CALIFORNIA, N,A, 11.49 30703
<br /> SACRAMENTO EAST BAY C(>MM0CIAp
<br /> L 4.ANW4G OMCF 1210
<br /> 1970 FPANnJN Sneer,OAKLAND,CA 94612
<br /> 34BO BUSKIRK AVENUE 5/23/2001
<br /> PLEASANT HILL,CA 94523-4342
<br /> PAY TO THE $ * 89A0
<br /> ORDER OF San Joaquin County Environmental Health
<br /> ♦###l�ktttx#k##'k## t##RR#it##kk'N#k};yi!!#rYYrff,fMt##ir�fi,k*#�#*MkR#iFt4ikhNYrYrf*4ftti*W,F:kikfktt#tf4R%##3< RNA :Yi#ltiaktt#w DOLLARS
<br /> Eighty-Kline and 00/100
<br /> San Joaquin County A(0) GNA S REQUIRED OVER$300.00
<br /> Environmental Health C
<br /> 304 East Weber,Third Floor
<br /> Stockton, GA 95202
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<br /> MEMO
<br /> Boring permits-S. Hollands
<br /> 11,0001070311" 1: 1 2 LO0049 71: 715017` 5r:126112
<br /> T!-.L F,EVER`.iL S:`JF (I lFilS Or iitJ�t:N C 'vlL' T!-l,iL`[ =�N Af'==Ti Ir'.IRt. 4V�!'1:'33MFaFK 01')W 1)S,11 Eli f'•l,9 TOCIi:.1r111 1}Si;,.Api i :5 if PA[FC;:i i };BTEC=`s3
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