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05-18-2001 07:44AM FROM TO 19166358805 P.02 <br /> WEL "PERMIT APPLICATION SITE <br /> rSAN JO LQUIN COUNTY PUBLIC HEALTH SERVIC M1TfGAT10N <br /> X00 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) AIT {V <br /> 304 E.!Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-RP-FUNDABLE PERMt17 5XEMg$1 YEAR FROM DA;{.•,E ISSUED <br /> Appiicatlon is hereby made to San Joaquin County fo'r a permit to'construct andlor install the Work described.This application is made in compliance with San <br /> Joaquin County Develo me T e,Cha t r 9-?11 ,3 a Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location Foss Street City Zip Parcel# <br /> PROPERTY Owner Me. lC ff fri�r��i Address___1 t�j�6 n(. I�?�y4x: Clly d t Zip yS ZyDPhone# <br /> C-57 Contractor 6-r Dr;l(,' Address ` 5a i�we P � •.__,_city /y/ Baez Zip /Phone: 2S 3/3-56CO <br /> Consultant I Sub Contractor �(� Address_Z ! 1'iasQecf{��piCiryl��i•�c �e�ic# Phones; CylE �/yy v��3 <br /> GIS Coordinates:X _'y ,Township Range Section <br /> WORK TO BE PE MEQ: <br /> NEW WEL O NG CPT,GEOPROBE.HYDWPUNCH,HAND-AUGER,OTHER-} Q DESTRUCTION(choose type below) <br /> ,SOIL BORING# 1Jk � 1�i-L r., {?�-3 0 OVER-BORE <br /> 11 WELL# 0 PRESSURt GROUT <br /> "Other. f (11 Grout Specifications: n <br /> COMMENTS: C 11..e <br /> TYPE OF WELL <br /> INSTALLATION C N' T <br /> I N TYPE � O S R qrTiON <br /> S != <br /> CFI A <br /> C TIONS <br /> 0 MONITORING 13 HOLLOW STEM E DIA, OF SOREHOLE MULTIPLE CASINGS?BYES ONO WELL CASIha OIA_ <br /> B EXTRACTION B AIR HAMMER1DRIVEN. CASING'THICKNESS TYPE 01=CASING: B STEEL Q PVC B OTHER. <br /> a VAPOR a MUD ROTARY ? DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS B HOSE <br /> B AIR SPARGE B PUSH POINT GROUT SEAL PUMPED: a Yes B No (NOTE: MAXIMUM FREE-FALLDEPTH IS 30') <br /> 9� OIL BORING B HAND AUGER GROUT SPECIFICATIONS: <br /> B OTHER: THER v fug'" ;t APPROX.BORING DEPTH B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSE()? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BOR,INGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECT R 48 WORKING HOURS IN ADVANCE FOR ALL REQUIREbjNSPI=CTIONS. jl <br /> I hereby'certify that I have prepared t�is application and that the work will be-done in accordance with San Joaquin <br /> County Ordinances, Rules and'Regulatlons, and all applicable California State Laws. <br /> Signed k fi— TitlelCompany <br /> Print Name: Sateapo <br /> s DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES <br /> WORK PLAN DATED: <br /> ff cep <br /> Applicatlon Accepted By Date Issued 3t l Are-e Ti `t Z <br /> Grout Inspection By. Date Final Inspection By pate Ld (} <br /> Destructionanspection By pate <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE CD BY DATE PERMfT!SERVICE REQUEST# INVOICE <br /> C-57 WCC WAIVErR C-57 letter of Authorization to sign permit Encroachment doc— 9/27/00 <br />