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08/03/2000 11:16 21094683433 FIFTH FLOOR PAGE 0 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUSL1C HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PNS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />_c!;caticn i5 hereby made :o Sar ;cacuin County tr a permit to c^nsVLG! andlor install the work daaenbed- T'Yis application is made ;r.Ct]mg1r2^CH .v Ch San <br />acwm Ccunry Development TI[le, Chapter 9-' 115.3 ane the Standards cf Sar ..capu r Cpunri Fadlic Heait;-1 Sar„ices. 'Environmental Health Civision, <br />Assessors <br />ELL Location ICSec.), Cross Street'16L aty ��n o-�i Zrc <br />RCPERr( Owner G � c �/?'l–c Address �h/ City ; Zip i Phoneme <br />-57 :;ontractorl%i.�—� % ;� t– Address `/�E ltc� �. �f Clr nom - 7i LiC'� CPhanerr <br />�57 lb^%Tj Ljl <br />—� p 1 <br />onsuitant; Sub Contractor(rJ ,/i7�s,ijr�/ AC Cess_? ` CityLic,:C'( Phonex cam` <br />\ <br />,S 'ccrdinat2s: X Y Township l <br />Rarge Sect on <br />.^.RSC TO 3E PERFQRMED� <br />NE'rV 'NEL L / BCRING ( COT. GEOPRCBE. Hl'DRCPUNC`i, Hr.tiD-aUGEq, OTHER”�DESTRUCTICN choose type below) <br />Il SCIL BORING _ OVER -BORE <br />Q WELL 7 PRESSURE GROUT <br />)then_ GPCUT SFECIFiCATION_( ��1( <br />4 iMMEN T S: <br />/PA/ W 5 I,," 4U� �" <br />.�CQ .� LU � <br />i� 6S <br />(PC OF WELL <br />INSTALLATION TYFE <br />CONSTRUCTION SPECIFICATIONS <br />r' ' CRIN <br />0 HCLLOW STEM <br />DiA. OF SOREHOLE <br />MULTIPLE CASINGS? [] YES ONO W ELL CAGING OiA: <br />E.X_RA.CTICN <br />0 A,R HAN1MSR/ CRIVEN <br />CASING THICKNESS <br />TYPE OF CASfNC: [j ST=E_ a PVC 1] 0TH -R: <br />VAPOR <br />0 MUD ROTARY <br />DEPTH Or GROUT SEA.:. <br />i REN1VE TYPE 70 5C 1JSE0. 13 AUGERS OHOSE <br />SPARGE <br />0 PUS4 POtrrr <br />GROUT SEAL PUMPED: C Yes <br />C No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />SCIL BORING <br />0 HANG AUGER <br />GROUT $P=CIFiCATICN <br />07HE t:Q <br />CTf^ER <br />APPRQX_ BORING DEPTH <br />❑ e0L T EC T'RAFF!C 8CX or Q STOVE PIPE <br />l <br />CONGUCTCR CAS[NC P4CPCS-D^: (iI YES, list specificaticrs here): <br />OMMEN TS <br />NOTE: OFt=SITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />-►ereby 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 UNIT IV :NSPECTCR 48 WORKING HRS IN /ADVANCE FOR ALL REQUIRED INSPECTIONS <br />ed <br />;nt Name - -- ✓��'t —%%�c� _ Oate_ C// <br />SI -7E MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED <br />;01i::a'won Accepted By <br />'nsoection By <br />>s� c:icn ;nsoection By <br />�XMMENTS ! CONDITIONS: <br />ACCVt,NTiNGONLY: I Alc)v <br />Cate 0 / <br />rU bV T <br />FSnaf (nspecdon 8y Date <br />3E :ODES I REE INFO i AMOUNT REMITTED ( CHECK # S RECD BY � DATE ` PERMIT/ SERVICE REQUEST # 1 INVOICE �! <br />C-37� WC/'NAwVER C-�7 L2tter of Authorizaticn �0 5ign permit lrncroachrrtert doc 7/17/CC <br />S� o v �� �`� S o ►� <br />