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FIFTH FLOOR G TO <br /> v <br /> 0 2/23/2001 10:05 2094683433 �.✓ u F S <br /> WELL PERMIT APPLICATION FORM MIOPM <br /> T GATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION CAH 95202, t <br /> 304 E.Weber, Third Floor, tOC on, orf <br /> f <br /> (209) $ <br /> MIT EXPIRES YE FROM DATE ISSU D li nce rv,th San <br /> NON-REFUNDABLE PE This application is made In compliance <br /> Environmental Health Division. <br /> Assessb's <br /> Tide.Chapter 0.7115.3 and the Standards of San Joaquin County Public Health <br /> services Quo Parcetit <br /> �IicaUon is here-by ae t0 San Joaquin County for a permit to construct and/or install the work described, <br /> ,quin County DevelopmentCity LP 5 <br /> I y I6 Cch+�, Glib Cross street rhone# `v <br /> ¢LLLocation / �� CityJ� ZiP� <br /> Addressi �i�• c14571 Lic4P Pf'onefl o <br /> tOPERTY Owne - ` ` Z�p_� <br /> ccn Riv.�r Rd city SMt�- ,6 1 4'+ tY <br /> .57 Contractor. t << Address i�✓� ,h PC.# 220 Phonelf t�ZS SS -� 4 <br /> .._�►hC- Address-- Section <br /> ,nsulnnt/Sub Contractor Range <br /> .Y .Township <br /> is Coordinates:X rJlooce type below) <br /> p OESfRUCT►ON8(OVER-80RE <br /> IO K TO BE PERFORM D: Q PRESSURE GROUT <br /> f1EW WELL I BORING(CPTQ SOIL BORING#DROPUNCH.HAND•AUGER,OTHER) <br /> �NELL* MKJ- Grout Specifications: <br /> Other: tl <br /> ;,OMMENTS: <br /> CONS ICTION SPECIFICATIONS CASINGS?Q YES No W ELL CASING DIA: <br /> INSTALLATION TYPE ' MULTIPLE <br /> TYPE OF VYE L DIA OF BOREHOLE.. TYPE OF CASING: 0 STE LC II OTHER. <br /> ,MONITORING HOLLOW STEM Q AUGERS AIOSE <br /> D EXTRACt10N Q AIR HAMMERIDRIVEN CASING 7:GROUT <br /> ESS_AL _ TREMIE TYPE TO BE U SED: 0 <br /> p MUD ROTARY DEPTH OF GROUT SEAL__ No _NOT : MAXWUM FR�E-FALL DEPTH IS 30') <br /> Q VAPOR GROUT SEAL PUMPED: ` Yes 0 �c ,, _ <br /> D AIR SPARGE ❑PUSH POINT py' U <br /> HAND AUGER GROUT SPECIFICATIONS: 1 i�[hOLTED TRAFFIC BOX °r 13STOVE PIPE <br /> Q SOIL BORING Q APPROX.BORING DEPTH P'1� list specifications here): <br /> D OTHER: 0 OTHER_�� p (if YES, ' P <br /> CONDUCTOR CASING PROPOSED? .� <br /> •COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCOROALACR ou RED INS EC IONS. <br /> CALL THE UNIT IV INSPECTOR 4s WORKING HOUR5 IN ADVANCESan <br /> done in accordance with San Joaquin <br /> 1 hereby certify that 1 have prepared this application and that the work wll <br /> les an gu tions,and all applicable California State Laws. _ Ham. <br /> County Ordinan . ��� r <br /> TldelCompany O <br /> Signed x Date <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3 <br /> WORK PLAN DATED: Q 1 Area <br /> Date Issu X.Doate <br /> Application A�cpted By Date Final Inspection By <br /> Grout Inspection By Datey <br /> peslrucUon Inspection By • .r <br /> COMMENTSICONDRS <br /> ION : <br /> ACCOUNTING ONLY: AIDi1 RECD BY OATS ft PERMIT I SERVICE REQUEST INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK i L <br /> OV w <br /> 140 9/27/00 <br /> C-57— WC;WAIVER_ C-57 Letter of Authorization to sign permit, Encroachment doc_ <br /> FEB 23 ' 01 10 :00 2994683433 QAGE .002 <br />