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04/18/2001 12 21 2094683433 r•I ` r�ri <br /> WELL PERMIT APPLICATION FORM <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 93202 APR 1 B 200 OFT(209) 468-3446 /� <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DDATE ISSUED El�'VJ�`,I 1i+i' =+ ? k'-;, t_`-'� l S <br /> Appl,ca`jon is hereby mace to San icaquin Coun'y for a parml'to const*u�anc'or instal,the wcrx oescribed This appkcatiDn�3�rle Ir,PgTp lance,+L n <br /> Joacu n County Development Tale Chapte,5-1118 3 ano the Standards of 4 nJLac u n Lip4�Pubk Hea h Services Env ricnmgl°at Health-Dival6n <br /> N �}-V ,4ssessot's <br /> WELL Location C c " L tt,4 �D C oss St*est Cay �1�or� Z�p?.fAO7 Parcel# <br /> PROPERTY Owner Cr o 7- 4/4.11 Add^ess �4Aj A4 R_/ City r11' _Z�p d2 Phone <br /> 37� <br /> C-57 Car'sactor fj004'//!J4f3' Address 450 l7oe�P 4O_14f Clty f e eZ. Z'p <br /> 07 4F <br /> Consultant!-3trbL°'~'rireet•�r t. 7 tills- Address E �4+w�i CItyL! t�c#Sl��s7—Phore#L��66�f�aa <br /> GIS Coordinates X _,Y 7o yrship 2 It/pol Range 671eise _Seclion,r a <br /> W Rio TO BER FORM D <br /> n VftI:J BORING(CPT G=OPROBE,1-*'DROPUNC C AN SAUCER,OTHER') 0 DESTRUCTION(choose type below) <br /> VSOIL BORING P (I OVER BORE <br /> WELL# �-.'� o14=,4 4 Or4 otn � roe vsa a PRESSURE GROUT <br /> 'Other .77C fA?? o*eLlje i,e t r' i. �►r�rw Gran•Spec ficat#ons <br /> COMMENTS CP I'V5 4,d AVAliftA,14 ee.a71e} far1x <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATiD S <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE I r� MULTIPLE CAS'VGS1[)YES 0 NO WELL <br /> CASING DIA <br /> []EXTRACTION 0 AIR HAMtt ERIORIVEN CASING THICKNESS—TYPE OF CASING [] STEEL 0 PVC 0 OTi-ER <br /> [i VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA_ TREMIE T"PE TO SE USED [1 AUGERS []HOSE <br /> 4'Y�SPARGE III PUSH POINT GROUT SEAL PUMPED 0 Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30) <br /> �rSOIL BORING [1 HAND AUGER GROUT SPECIFICATIONS <br /> BOTHER Cis Q OTYER APPROX sORING OSPTY Ll f _ (] BOLTED TRAFFIC 80X or 0 STOVE PIPE <br /> &7 C N1 UCT CASIN °R SEDT (if YES�I's,sDeafca'ions here <br /> `COMMENTS �rtdJ�� v G � <br /> NOTE: FSlTE BORINGS REQU! E ACCESS OR ENGROA HMENT PER S. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin <br /> County Ordi nce Rules and Regulations, and all applicable Caltfornla State Laws <br /> Sigred x �r T��e CaTFary� •r• G �'U M <br /> P,rntNarre —oats <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESS: �"S A <br /> WORK PLAN DATED: aD O 3 <br /> 34 <br /> Applleation Accapted By <br /> Date Issued e- G Area <br /> Grout inspection By Date Final Inspec'ion By Date <br /> Destrucb,on Inspection B Dale <br /> COMMENTS!CONDITIONS <br /> ACCOUNTING ONLY A D4 L <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE= PERMIT/SERVICE REQUEST# INVOICE <br /> �j 0 O -0l ©QT��4S <br /> C-57 WC -WAIVER C-57 Letter of Authorizaticn to sign permit > ncroachment doc ✓ 9/27IQC <br /> E0 EEVEE91762Z 69 .6: 00OZ/6I/0Y <br />