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02/23/2001 10:05 2094683433 `- <br /> FIFTH FLOOR <br /> A 62 / <br /> r� <br /> WELL PERMIT APPLICATION FORM SITE <br /> 0 AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E-Weber, Third Floor, Stockton, CA., 95202 <br /> Zv (209) 468-3449 <br /> 1 gLN_,o 2EFUK ABL£PLM_IT EXPIES LYEAR FROM DATE ISSUER <br /> ;pphrattcn is hereby made to San.Joaquin County tore permit to construct and/or install the work described This appl,catlon is made in cornpltance WM Sart <br /> loaclutn Coyfity Developrnenl Title Chapter 41715 3 and the Standards of San Joaquin County Public Health Services,Environmental Health Diws,an <br /> NELL L eativ�n <br /> ♦ ��/ y AS56S50t'S <br /> Cross Streat ty. 5ln _-z,p95ra� _Paroell'F <br /> PROPERTY Ovrner [ �r_ chess l� Gty c ZrpgS-��Qhone# S <br /> C� Ar <br /> C-57 Contractor Address L - - - C, + 4rc#M-6 hon 7 <br /> Consultant/Sub Contactor rt Rridressa4 it+rrL_ C+Iy� �t ict� Pl�nn Zs�- <br /> GIS Coordinates X Y Township Range Seaton <br /> 199EK TOS PERFORMED <br /> a NEW WELL/BORING-(CPT GEDpROBF HYEIROPUNCH N •AU ER,OTHER-) 13 DESTRUCTION(choose type below) <br /> Soft.BORING# — d OVER-BORE <br /> 13 WELL IR 0 PRESSURE GROUT <br /> 'Other Grput Spt:c,firatttans <br /> COMMENTS <br /> TYPES O. F WE" LNU&ILATION TYPE CONSTR C IONP TCATIONS <br /> q MONITORING D HOLLOW STEM p1A-OF BOREHOLE I++ILILTtPLE CASINGS Q Yr~S WUO W ELL CASING CLIA <br /> q&qAC7nON Q AIR HAMMERIDRIVCN CASING THICKNESS VPE OF CASING I]STEEL i]PVC 0 OTHER <br /> R 1)MUD ROTARY DEPTH Ot=GROUT SEA t TREMIE TYPE TO$E USED 13 AUGERS +Hose <br /> QAIR SPARGE IRPUSH POINT GROUT SEAL PUMPEO r Yes I7 No (NOTE MAXIMUM FREE-FALL DEPTH 15 30') <br /> 1 SOIL BORING 13 HAND AUGER GROU`f`SPECIFICATIONS <br /> 1)OTHGR n OTHER APPROX GORING DEPTH 0 BOLTED TRAFFIC BOX or 13STOVE PIPE <br /> - -` — <br /> —CONDUCTOR CASING PROPOSED? (if YES,list speafiratrons here) <br /> -COMMENirS- — — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL,THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby cerltfy tlta hav prepared this appllcatson and that the wank will be doffs IR accordance Z- <br /> all <br /> San Joaquin <br /> County Ordttta s, es est "pn Otto applicable California State Laws SEgnetl x TltlelCompsrr �l �" - .n <br /> Print Name /7�/��✓ pate -3l " <br /> ttDEPARTMENT US/E�/�O�NLLY <br /> 17l!�� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 � � CY-Z4 p GT -' <br /> WORK PLAN DATED: -Z ­0/ <br /> Application Accepted By za�� <br /> Gate issued„ ! l - - Area <br /> Grout trispedion By. pate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONorriON3 -.f • �P� � `r IIF-.10� a/ <br /> OUN'TtN13 ONLY At04 <br /> PE CODES FEE INFO AMOUNT REur1TED CHECK# REC'D BY DATE PERMIT r SERVICE REQUEST 9 INVOICE <br /> / �- g <br /> C-57 WC,-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> FES 23 01 IO 00 <br /> 2094683433 PAGE 002 <br />