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03/04/2004 15 00 20946210H FLOOR PAGE 02 <br /> 10-24-2800 03 40PM FROM (C- (D1PNTO 153857660135 P-02 <br /> !C[":5 ED WELL PERMIT APPLICATION FORM SITE <br /> OCT 2 4 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENT HEALTH <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton,CA., 95202 <br /> (209)46s-3449 <br /> -REFUNCASLr=PE12MIT 21'M Pt 7 YflAR FROM 06M MEA <br /> ApplimatvA w itien~Dy n=de Ic San Joaquin Carinly for a permit to construd andlor install the wort desciaed This appHcatlon Is made in=M*M08 with Sar, <br /> Joaquln County Development Me,Chapter&111 S-3 and ft stan4aras of San(Joaquin County PublicLHtealth Services Ernrtronmenta€Hea€t€ti t3�lon <br /> Aca Me' <br /> WELL Lvcaa" 15 Cass rlTC .�fIc Crnss StreetL�./Qf V'4( _fAtY ��.t+�►LIs'`l T1a Parva f �-a3 <br /> PROPERTYOwner Y kiN rAddre _ �r3_/'�. CT _C,ty 51�EkiI61A ZO 9.5 Fn a�`t- <br /> CST contractor rests, SSo--i%Q CA WC.p'p,100ts�c c <br /> Consultant)Sub Cvntracta 5w*NVa M AAAddr---�33D(�, �rtC Rt. c�•afC urc pr,one#530-67h1dbb - <br /> p <br /> X13. <br /> Y5G8� <br /> GIB Coosd,natas,X - _ Y T4+vh8h[� Range Smon. ._-_----.. <br /> WORK TO SE-P 8 D <br /> NEW WELL I BORING(CPT,GEOPR03E.h-YDROPUNCH,HAND-AUGEI t OTH51it-) 0E5TRUGTI0N(choose t90 below) <br /> U SOIL$0 IN * -� ` a WER-SORE <br /> �:►NELL ri rd. j PRESSURE GROLt7 <br /> *Other, Grout speeAcatrons <br /> COMMENTS. <br /> met or INSTALLATION TYPE CONSTRUG20M SpEnwICSTIONS <br /> *Q (TORING ]1'.HO I-ow S"l1'r-m DIA.OF BOREHOLE _MULTIAL.E CASINGS?a YES VO WELL CASING DIA._?.__ <br /> .Q 07PACTION 0 AIR HANMERMRWEN CASING THICKNE .fit] TYPE OF CASING o ST.F.Q. QVC D OTHE=R <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEA TREMIE T"PE zU BE USED. E <br /> IJ AS SPARGE a PUSH POINT GROUT SEAL PUMPED )(Y. MII <br /> Na {N TE: AXIMUM FREE-FF1�T�-l� <br /> C]SOIL i30PING a HAND AUGER GROUT SPECIFICATIONS <br /> 1)OTHER n OTHER APPRM BORING DEP fi! u haj --j----- OLTED TRAFFIC BOX or JISTOVE PIPE <br /> I CONDUCTOR CASINO PRQPQSED" f if YES,list specifications here). <br /> -CC9MM5NTSa <br /> NOTE: OFFSITE BORINGS RECWIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL TKE UNIT IV]INSPECTOR SFS WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby cartlfy that 1 have prepared this appilr„ation and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State/Laws <br /> Signed x l�;d�,+ +- 5- 5�''�1�'la <br /> / gA <br /> Print Name_--StA i►^ a._ _ �}a!e h)n[--D-3 _ _ - <br /> DEPARTMENT USEONLY <br /> SITE MAP EN UNrr 1V FILE,A DRESS' Z 5'0 �taC.�. �- ---- -- <br /> WOPM PLAN! DATED: r ,-) l / <br /> ARpll�on A=eptsd By ,,, U .t�of-++ --- Date l3sut d � AreB 19 <br /> Grout Inspt:s on BI' Gars Final Inspection Bn l <br /> Desi ction Inspecwn By Cate <br /> COMMENT$/COHD1T1g NS <br /> ta <br /> UMrING ONLY' AlLM <br /> t)ES FEE INFO AMOUNT RENfl-M CHECK-9 RECD SY DATE PERMrr I SERVICE REWEST� INVV09 <br /> C-57 WC -WATVEA— C-37 Letter of Authorization to sign permit,,,,,,-Encroachment clic 9/27/00 <br /> TOTAL P 02 <br />