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02/23/2001 10:05 2094683e• FIFTH FLOOR : PAGE', � <br /> WELL PERMIT APPLICATION FORM �1T1G�Tl0� <br /> ltl <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV � <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PE MIT EXPIRES 4 YEAR FROM DATE ISS s D application is made In compliance with San <br /> >pplication is hereby made t0 San Joaquin County for a permit to construct and/or install the work described. S PP Assessors <br /> Joaquin on is re 3 opment Title,Chapter¢1115.3 and the Standards of SanJoaquinCounty Public Health Services,Environmental Health Division. <br /> 1 r5 Fkn ity Zip`IS_ ?-�Z Parcel# <br /> NELL Location Cross Street �� Zt33$ <br /> ► .,,m#, Zp`±:Ej Phone#_ <br /> PROPERTY Owner, f -� J � b Address �0-`�`�� `Ci1 i <br /> ty <br /> SLOA P(�CJC=- Ciry Zip <br /> SZSZIi 65-pttoneft '1037 fS�3 <br /> C-57 Contractor N✓/� Address. - wiz 220 '93 <br /> Z Address � S Gtrc C{ _City n" <br /> (i h Lic# Phon 2S .SSI-7'S S� <br /> Consultant/Sub Contractor r' Section <br /> GIS Coordinates:X •Y <br /> Township Range <br /> WORK TO Be PERFORMED- [I DESTRUCTION(choose type below) <br /> Q NEW WELL I BORING(CPT,GEOPR08E.HYDROPUNCH,HAND-AUGER,'T PRESSURE GROUT <br /> IR 0 OVER-BORE <br /> SOIL BORING a C <br /> a WELL# Grout Specifications: L`'' ✓' <br /> *Other: <br /> COMMENTS: <br /> TYPE_OF yyEh INSTALLATION TYPE CONSTR CTI N P 1�-t�MULTIPLE CASfNGS?Q YES O NO W ELL CASING DIA: <br /> HOLLOW STEM DIA OF BOREHOLE <br /> Q MONITORING Q TYPE OF CASING: 0 STEEL 0 FVC Q OTHER;_ <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: Q AUGERS HOSE <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: �Yes p No (NOTE: MAXIMUM FREE-FALL-DEPTH IS 30' <br /> SOIL BORING jI HAND AUGER GROUT SPECIFICATIONS: <br /> APPROX.S BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER:-0 OTHER,`— (if YES,list specifications here): <br /> CONDUCTOR CASING PROP SED?_ , - <br /> 'COMMENTS: <br /> NOPE; OFFERMITS <br /> SITE BORINGS REQUIRE ACCESS OR ENCROACHMENT 1 �NS EC ONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br /> certify that I have prepared this application and that thettl be done State Lawsn accordance with San Joaquin <br /> I hereby ce Y applicable California C. <br /> County Ordinance ,Rut a Regula 'ons, and all a po rs �r —f� �, <br /> TittefCompany f <br /> Signed x � pate <br /> Print Name h L DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED; -O40P <br /> ��Q f Area D� <br /> Date Issued Date <br /> Application Accepteday Date. Final Inspection By <br /> Grout Inspection By ' <br /> Date <br /> Destruction Inspection BY <br /> COMMENTS I CONDITIONS-- <br /> ACCOUNTING <br /> ONDITIONS:ACCOUNTING ONLY: AIDti PERMIT I SERVICE REQUEST# INVOICE <br /> ATE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK;t RECD BY D —9 01 �ZS 9/5 65.51F9/27/00 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc <br /> FEB 23 ' 01 10 : 00 2094683433 PAGE . 002 <br />