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12/11/2000 12:35 53075GlF,48 ASE INC • PAGE 01 <br /> WELL PERMIT APPLICATION FORM <br /> ;TIGATION <br /> UNIT IV <br /> DEC 0 8 2000 SAN JOAdUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRiNMEN'C HEA011, 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERI 91T/SER�lIC� r (209) 468.3449 <br /> p (lance with San <br /> N N R FUN ABLE PERMIT EXP RES J YAR"RO DA E ISSUED <br /> O Assessor's <br /> 7iJt�, o ou,g or a pem Standards ct San Joaquin the woo Public Health Service%,Environmental Health DDiivissiOn.,_p <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This a pliCatton Is made m Com <br /> rjjhe <br /> Joaquin Countypeuelr�°t}e Zip � Parcel# <br /> l 909 N•F"cr.y eo..t cross street (l 7W[ ,piY - ✓� d f(S^ <br /> WELL Locationw �� /r„/,', At YZYr! Phone# <br /> gQbA lAA-J" l `�Addrass :----f-'=`City ('ems'--Zip-��'� <br /> PROPERTY Owner_,.,,..,...— _I r� >) Lic#7/7 Yro Phone# y'iY'll <br /> ^ '3631. 0 0dty . CarJiew'.Zlp <br /> C-51 Contracto&wra 1/r i( t""�—Address Colt 11(�Phone# d Sy -2'L�' <br /> 9g ,7p ryo City ,S LIc# <br /> QC t L Address h „ <br /> Consultant!Sub Contractor Range,,,__., -G Section <br /> TOwnsnSp -�� <br /> GIS Coordinates:X� Y <br /> �DESTRUCTION(Choose type below) <br /> WR K BE E RO MEDS DOVER-BORE <br /> W <br /> WELL BORING(CPT,GrOPBOOBE R NG#DROPUNCH.HAND-AUGER,OTHER') 0 PRESSURE GROUT <br /> n WELL# Grout Speclficetlons: <br /> 'Other: <br /> COMMENTS: <br /> N <br /> .fI,PE P.W LYf <br /> TALLATK)N TYPE CON. TRUC lON S ECIFICATIQtIe <br /> IN pCHOLLOW STEM DIA.OF 60REHOLE h• MULTIPLE CASINGS?OYES �N.O ',rWELL CASING DIA: <br /> hfMONiTORING 5C/{ TYPE OF CASING' 0 STEEL (YrVC 17 OTHER; <br /> 1a EXTRACTION a AIR HAMMER/DRIVEN CASING YHiCKNESS_J,,,^.�..-- TREMiE TYPE TO BE USED: 0 AUGERS sRK6SE <br /> 0 VAPOR MUD ROTARY DEPTH of GROUT SEALNOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: [I Yes p { IV, r, t <br /> n+r,G,.7-' Tyr <br /> p SOIL 50RING U HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or OTOVE PIPE <br /> r <br /> [1 pTHER: _p OTHER APPROX.BORING DEPTH_, 0 --p <br /> CONDUCTOR CASING PROPOSED? All> (if YES,list specifications hera):-- <br /> coMMeNTs: r9 tJ l m,tit.vG W eczc.� 71" 2 <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 /> 1 hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin <br /> County In �es, les and Rees, and all applicable California State Laws. <br /> �'�p Title/Company <br /> Signed x <br /> Date Y. rr pr] <br /> print Namei rep ,"IsTk a DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I l� �Qt" 1 I -31 <br /> WORK PLAN DATED: 11 2 po � g^ <br /> Date Issued Z Area t�.D <br /> Application Accepted Ey peteC7 <br /> Grout Inspection By ,�-/R�� Date Final Inspection By <br /> De%trUCUon Inspection BY Date <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECKS RECO BY DATE PERMIT/SERVICE REQUEST r INVOICE <br /> mol ;?47 - 41 1241 00 00 807 <br /> 7/SU <br /> C-57_ WC_ WAIVER_ C-57 Letter of Authorization to sign permit__._Encroachment doc— 9/2 <br />