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WELL PERMIT APPLICATION FORM Mei DATION <br /> SAN JOAQUINCOUNTY PU.f3ilcHEALTH SERVICES UNtT�;;l� <br /> ENVIR )NMENTALHEALTH DIVISION CA 95202)rY 0 9 2003 <br /> 304 E.Weber, Thi( tan, <br /> 2 9) 468 3449 <br /> P'MS'1 YEAR FROM D TE ISSUED <br /> pp EFUNDABLE PERMrt EX Iiwtien is made m ccmPtia"ce wr li Ban <br /> Joaquin CDynry kr a permit to Censttuct andlvrtnstell the <br /> wwk described. Thk aPF msessoes <br /> um county Public Health Services Envlranmental t(elalltt Olvison r r <br /> tpplleation is hereby <br /> made ld San SZ( paroalg�r— <br /> loaquinCountyDe,,elopmentTitle,Chapters•11t5.3andtheStandardsofBan.lCaq " \ u^ P 4 <br /> _ Av c S zt D`i— <br /> ti rl? C (' �i„Cross Sweet �r� 5' +�n Zp S1GlPMrtaF Z�r— j <br /> (). u c �i Z <ityF71 SI O F,nonefs <br /> HELL Location Address YS? <br /> Lir / Gty �LiG7 <br /> PROPERTY Owner L y- Ike pclC p(ase S3)�DI �3d ' 4$4 /00 <br /> C 5 c 4�t c,.,+� e Svc, Lie% PhoneB�-- <br /> C•57 Contractor S —City <br /> G I„ �Addresc ! i 9! 1 4 section <br /> Consultant I BUD Cantraaor Rangef� <br /> Townshlp��� <br /> Y—^�� ' -(�� (oc�.4, <br /> GIB coordinates;X Sem t..c(cj e� �" ',5 u.^o O DESTRUCTION(Chadse tyPebelow) <br /> D OVERBORE <br /> WOR TO BE PERFORMED: Il PRESSURE GROUP <br /> pNEYy WE lBORING(CPT,GEOPR00E,HYDROPUNCH,HANG-AUGER,DTHER7 <br /> SOIL BORING I <br /> XWELL p Grout Specifications: <br /> 777 <br /> s / <br /> other, 2 k f roc [v <br /> COMMENTS: 0,2 YES NO WELL CASING MIA: <br /> �/— <br /> OF WELL 1NSTALLATIONiYPE 7:. 80REHOONSTRU 0'L PE$tF�.—= NS VC OOTHER: <br /> E'—V—' ��_ c 'r MULTIP F OF CAsi? - <br /> ALLOWSYEM TYPE OF CASING: DSTEEL �'' HOSE <br /> D MONITORING TREMIE TYPE TO BE USED: AUGERS D <br /> EXTRACTION pAIR HAMMERfORI`fEN O�PTHOFGROUTSEAL�— <br /> O MUD ROTARY No NOSE: MAXIMUM FREE-FALL T)FPTH IS 30'� <br /> t]VAPOR GROUT SEAL PUMPED: ayes ONO i r SCC m o < <br /> p PUSH POINT BOLTED TRAFFIC BOX er O STOVE PIPE <br /> D AIR SPARGE GROUT SPECIFICATIONS: C <br /> O SOIL BORING D HAND AUGER NG DEPTH <br /> APPROX.BORT (It YES,lief specificaticns here7t <br /> O OTHER:..........0OTMERr” CONDUCTOR CASING PROPOSSO?� <br /> -COMMENTS': <br /> NOTE: OFFSITE BREQUIRE ACCESS OR ENCR ALL REQUIRED INSP <br /> "RINGS ROACHMENT PERMIT <br /> CALL THE UNIT N INSPECTOR 48 WORIpNG HOURS IN ADVANCE FOECTION <br /> rad this application and that the worCalifr will <br /> Laws.be don 9 in accordance with San JDaq ' C <br /> ia <br /> (hereby certify that 1 have prep ations,and all app _ E C <br /> Rules a d Rag Talelcnmpart <br /> CountyOrdinaDa �_ p <br /> Date <br /> Signed x �2((? G III <br /> Print Name oµ^?S C• WARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: O <br /> DATED: Area <br /> WORK PLAN Date issued l�\.t.�rrv,n —Date <br /> Final IPS n By�•— <br /> Apptiratlen Accepted BY Date <br /> Grout Inspection By Date <br /> Oesaucden IruPsrtian BY <br /> COMMENTS I CONDITIONS E <br /> OICE <br /> c <br /> ACCOUNTING ONLY: AIS RECO By DATE PERMIT I SERVICE REDOES <br /> INFO AM �MriTeo OHECFC'J 2) <br /> PE CODES FEE AMOUNT O 1_� V 9IZ�rd� <br /> 3S o I C,57 Letter of Authorization to sign permit,-Encroachment dos, <br /> C-57,.• WCr yVAZVER� <br />