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06/19/2000 03:30 925-463-0959 ATC PLEASANTON PAGE 02 <br /> tat-f ta/14173. 10:13 2094E,. 33 F11FTH FLCOR PAGE 02 <br /> f <br /> . yam WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 93202 <br /> (209) 438%3449 <br /> !�} O FI} P R <br /> Application to Hereby made to San Joaquin county iku a permit to construct and/or Install the work dascrlbed. 3Ria application is made in cempl nca vAth San <br /> JCaquln CounryDevelo "IentTitle,Chapur i1-111S.3 and,the Standards of Sam.saagain County Puollc Health Servicee.Environmental Health Division. <br /> ���j <br /> Assessor' <br /> UELLL.o"tian ,r'� t/ <br /> PROPERTY Owner /Mil o/xQ/��/L/G cess 1' l .�T Ctty P Phos ✓� ✓i'�" <br /> C.57 Cont=ksr�' �/ / drras .iCity � hone* OIV',,p W'9-24-;;; <br /> �j�' �C. address S Gity �� ON /.0 Pnanede 91 '" ��`✓ dD <br /> Consultant!Sub Contractor�'v D <br /> }G15 Coordinates:X ,y Townsnlp Range �v S!=ttan �a <br /> I <br /> WQRK TO S.F.PERF <br /> p NEW WELL!BOWNtCi(CPT�Gs�OPROB6.HYDROP NCH.}�*-IJGEI�, 7 p bE UCTION(chaosa type below) <br /> 'D WELL tr RING Sy rSfirf`�, fdg 5� 13 PR> SSURE GROUT <br /> �'aOthvr. GrquL SpEC'jgeatirnta� � (J <br /> COMMENTS: <br /> OF ML INSTALLATION CO RUCTION RUSIMAMM <br /> CI MONrrr0MNG [[HOLLOW STEM DIA.OF BOREHOLP,. MULTIPLE CASINGS?Il YES Q NO WILL CASING DWA <br /> 13 EXTRACTION p AIR HAMMC-W0F IVSN C,AS[NIG THICKNESS TYPE OF CASING; 0 6MEL JJPVC q OTHER: <br /> OR [J MUD ROTARY DEPTH OF GROUT SEAL__ __ TREMIE TYPE TO BE USM. 13 AUGERS d HOSE <br /> i SPARGS PUSH POINT GROUT SL PUMPED: ras 0 No (NOTE.MAXIMUM FRSE-FALL DEPTH IS 30') <br /> � Q EAQ <br /> 0•SOIL BORING 0 HAND AUGER GROUT SPECIFICP.710NS: -- <br /> 13 OTHsFt-� 13 OTHER APPROX.BORING DEPTH ([BOLTED TRAFFIC SOX or El STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDT t i[YQS,Cst apecifcadcns herep <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQU[RED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances. Rules�and%Regulations and all applicable California State Laws. <br /> � ? T�lefCoirrpariyr t.� <br /> 5ianed x �7 � �i��600. <br /> -print Name 4/,Giiaie 1 <br /> DEPARTMENT—USE O Y <br /> SITE MAP IN [UNIT IV FILE,ADDRESS: - <br /> { WORK PLM GATED: 6 <br /> Apprrcabon Accepted SY Date Issued <br /> Grout Inspection lay data al Inspection By Date <br /> Besmrdlon Inspecdon By Date <br /> COMMSN TS 1 CONDITIONti <br /> OUNTINIG ONLY: AIDS <br /> E CODES FEE INFO AMOUNT REMITTED CHECK'S R1:6'D BY DATE Pi=RMIT 13 RV;CG RgQUEST S INVOICE <br /> �' 350 / Z4So <br /> C-57� WC r±/- RIVE 2 C-57 LP-tter of Authorization to sign permit 'Incroachriwt doe 9127/00 <br />