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Date Issued )pr.C.adon Accepted By <br />Date ?struction Inspection By <br />CHECK # <br />FAC.# <br />REC'D BY DATE E CODES FEE INFO <br />ACCOLNTING ONLY: <br />z5o2, (ob <br />Alpo <br />, AMOUNT REMITTED /SERVICE REQU <br />SR# OO 2- 7 3 <br />INVOICE <br />C-57 WC/WAIVER C-t.7 Letter cf Authorization to sign permit rtc <br />0 ? <br />3S(0 2-' <br />/ ,CO <br />rot..t Inspecon By Date Final inspecon <br />DM751ENTS ! CONDITIONS: <br />Area <br />/ <br /> uptit)')- <br />Jae 03/ 2000 11:1'; 20946833 FIFTH FLOOR <br />AGE <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />=I/cation is hereby made to San .:cacuin County for a permit to construct and/or install the work desdiioec,, This ap,plication is made in corniaiiente wirn San :acuin County Development Title, Chapter S-1 115.3 ana tne Standards of San Joaquin County Public Health Services. Environmental Hearth Division, <br />'ELL Locationlil• k tk-- Sk-ref Cross Streeterek-ftz...S, City reaCi Zip q3-1 ParceI# <br />, AsSaSsor's <br />IS C.scordinates: X <br />ORK TO BE PERFORMED: <br />NEW WELL' BORING ( CPT, GEOPRCBE. HYDROPUNCH, HD-AUGER, OTHER-, ZSES7R'JCTION (choose type below) EL SOIL BORING OVER•BORE WELL ti`. PRESSURE GROUT )ther: GROUT SPEC.:FiCATION <br />SITE <br />MITIGATION <br />UNIT IV <br />ROPERTY Owner <br /> . Township Raroe Section <br />G_14.01c ci-A 1/41 P <br /> ddeess (tio e- • 10 c,ty ci53-1S..Phar.# 1G 5 <br />7 <br />A-Y-1/4.1—(Y\ Address eg LO; ClryStackfok Zipq.DOT Lic#512;Zeg orie-AtAfg -57 Contractor <br />nsultant I Sub Contractor.1)CZ%‘4 ENO IcAtnti.c.iress (c,) 1.C • kc3-k-AN. City --r("Ckcc.i L;Cit- IRA PhOrle# 733C3.1 c?S <br />OMMENTS: (41A)-k-1 <br />(RE OF WELL <br />CCIONITORING,) <br />EXTRACTION <br />VAPOR <br />Ai SPARGE <br />SOIL BORING <br />OTHER: <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AR HAMMER/DRIVEN <br />o MUD ROTARY <br />PUSH POINT <br />HAND AUGER <br /> 0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />Di A. OF BOREHOLE MULTIPLE CASINGS? U YES 0 NO WELL CASING DIA: <br />CASING THICKNESS TYPE CP C.:ASANC.: (I STEEL n PVC 9 OTHER: <br />DEPTH OF GROUT SEAL 7REMIE TYPE 70 BE USED; U AUGERS OI-103E--. <br />No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFiCATION <br />APPROX. BORING DEPTH IJ BOLTED TRAFPIC SOX or U STOVE PIPE <br />CONDUCTOR CASING PROPOSED'? if YES, list soecincaticns here) <br />GROUT SEAL PUMPED; C yes <br />ommENts: '1-4-6A 14 LA) *3 ct e- t‘: lit 1.itn11rwc . ILY// ,elvx // ea we/yell:lea <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />aunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />*CALL THE IT IV IN FECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIO S <br />I i't• Tide/Compary Piuk_4ac. <br />Daze -c3A --CP I <br />SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br />DEPARTMENT USE ONLY <br />;red <br />irpt Nam