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06/19/2000 03:30 925-463---59 ATC PLEASANTON PAGE 06 <br /> `� WELL PERMIT APPLICATION FORM STYE <br /> lg mMITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209).468-3449 <br /> NON-REFUNDABLE PFRMiT EXPIR11 I YEAR ESONT 0V90 <br /> 1APPUCatio"Is hereby mads to San,joaavtn County for a permit to ecnstruct arWar install me work drsatbed. This applisatlon is made in=vnptiance with San <br /> JcaQuln CountyDevetapmentTIM.Chapter S-ii15.3 and-am Smndarda oI an/Join Gau*Public HealtthSAeivi=,Envimm <br /> nennth Division_ <br /> iw-_LLLc=t1Q' � �"' •/�u/ s Street e1� �r p Parcai= <br /> PROPERTY owner_ Clzy <br /> C-67 Contrdstor %�ef� �%P�7� dress. 7 �,�/s i' c#aJ�hone# <br /> Conmawf t/Sub Contmctor�r'"'Ar�r Addreas <br /> Cris Coeniirust=X Y _.Tcwnsrip fAlRange Sectlon ! <br /> 'WORK TO Be_P_ARq__1 M90: DEMUCTION(choose type below) <br /> (�NEW WELL/BORING(CPT?-;Wq <br /> COPRp6E.EtYa �j - OTHER) a �OVER <br /> OIL BORING <br /> ELL•. Q PREMRE GROUT <br /> Ocher. Cyreus SPerJIlcatlens: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYP2 CC}NSTFtUCTtOH SFECIPtf AT]OJ <br /> (j MONITORING Q HOLLOW STEM DIA.OF BOREHOL.fl�r,.„,MUL'Tlt�CASINGS?a YES B Nb WELL.CASING DIA:�,,,,� <br /> MONITCTIC�N WR hfA4tMERlOrZIVEN GASihIG TFiIGKNESS TYPE OF CASING: a STEEL Q PVC U OTHER: <br /> VAPOR d MUD NOTARY OEPTH OF GROUTS TR1�uIE 7Yt'E TO 6E USaO: �AUGT?RS Q ROSE <br /> I SPARGE p PUSH POINT GROUT SEAL PUMPED: 13 yes 13 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30' <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS' <br /> a OTHER: _ ---- _0 0TH ElkAPPROX.SaRING DEPTH_.^ [I BOLTED TRAFFIC BOX or t(STOVS PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES.Gat specifuatTons here): <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCS FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in aecardance with San Joaquin <br /> County Ordinances,Rules zy Regulations,and all applicable Califomla State Laws. <br /> Signed x <br /> I/G�pe�� /S�r3D oats Qom/ -IrJ/ <br /> Print Name ,DEPARTMENT U.^�E OriI Y <br /> SITE MAF IN UNIT IV FILE,ADD E <br /> WORK PLAN DATED: ro <br /> J d <br /> AppCccalion AccepkAd BY u t9sued IB ,L., Are ��„s� <br /> Grout I"Pectlon ay Oata Fins1 Inspecticm By Date <br /> Dez=ct[an Ins06C.dcn BY Date <br /> '� CflMMF.N'rS 1 CONDt'rlGtaS: <br /> A.CC.OLSNTING ONLY: AJ0%- <br /> CODES FEE INFO AMOUNT REMMED CHECK Z SZ~CID BY DATE PERMIT I SERV1GE REOUEST A INVCtCE <br /> � _0 ( fiY Z�fa aoZG�6 Z <br /> 9/27100 <br /> WC /-WAIVER_ C-57 Letter of Authorization to sign permit � Encroachment doc <br /> I� <br />