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' 03/04/2002 16:00 2094683433 FIFTH FLOOR <br /> r'« lnldl� <br /> /Z '2 16-12 2094583833 <br /> FIFTH FLODR PAGE 02 <br /> ' PACE 02 <br /> WELL, PERMIT APPLICATION FORM <br /> ' SITE <br /> SAN JOAQUIN ENVIRONMENTAL HEALTH DEPARTMENT (EHE)) D N <br /> 304 E, Weber, Third Floor, Stockton, CA, 95202 FDTZCOUNTY =,, <br /> " <br /> ' (209) 468344,9 c <br /> icationishemb NON-REFUNDABLE PERMIT ENV1R0i4 :�ILISTHEA IH <br /> yma�etoSanJoaquinCoun P PIRE5alltbe F OM DATE ISSUED PERV:.7SEHVIvES <br /> ty fora ermR to consbuct and/or install Ute work desLfbed. This application mn County Devalopment Title,Chapter 3f 1153 and tha Standards of San JoBgUin County Envfro <br /> PP n is made in compliance with San <br /> VELL rtmental Heal eparbnent. <br /> Cocatioft/y4�/ Cruss Street r���� oI D Assessors <br /> Ownerfa� -�- `1�- �City Frn�a�L' <br /> t <br /> ERTy " 1Addressi�Y% <br /> enlraUnr Address ii41 cS'e f �•'•r—CS L-.k,� Zp S o5 PhMe# 7rr9-_ _7349 <br /> ��_k� D 5�.. CI4' jP�`84�Uc#a, 3�ZPhormp <br /> vllantl Sub CvntrocMr-rT_�ro ro�io --5/O-��7-'Lr5T5 <br /> Address_i3�GNMw' lBlu�Ci,• r <br /> nilrwkes:X :`.Y smcrsatc.StaLidf PhoneC <br /> 31Sa-9aR-a z1,,, <br /> Township <br /> T DEPERFRRMH - •�— --_Range_ Selo <br /> WELL/BORING(CPT,GEOPROBE.HYDROPVNCH,HAND-AUGER <br /> SOIL BORING N G ,OTHER') a DESTRUCTIONchon5e <br /> kher. II WELL# ( type below) <br /> A OVER-BORE <br /> MENTS: Grout Specifications: 0 PRESSURE GROUT <br /> /PERF WELL INSTALLAT�pN-rypE cONSTRUCTtaN SP6CIFCATONs <br /> ITORING p HOLLOW STEM DIA.OF BOREHOLE <br /> IIRACT-iON -.!LrU MULTIPLE CASINGS?[jyES XNO VVELL CASING DIA: <br /> ,$AIR HAMMER/DRIVEN CASING THICKNESS �R <br /> V R TYPE OF CASING: <br /> 11 MUD ROTARY —AL U STEEL 0 PVC 0 OTHER <br /> 41R SPARGE DEPTH OF GROUT SEAL <br /> p PUSH POINTGROUT SEAL PUMPED: !1 y� —�EMIE TYPE TO BE USED: p AUGERS p HOSE <br /> BORING 17 HAND gUGE p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS; <br /> E��OTHE----_ APPROX,BORING DEM <br /> CONDUCTOR CASING PROPOSED'—' s a BOLTED TRAFFIC BOX or [1STOVE PIPE <br /> OR <br /> . ENTS: - t If YES,IistspedhcaUons herek <br /> NOTE. OFFSITE E BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 48 WORKING HD <br /> OURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ereby certify that I have prepared this application and that the Work will be done in <br /> Ordinances, Rules and Regulations, and all applicable California State Laws" accordance With San Joaquin <br /> r <br /> t A T"a Campa"y <br /> Name <br /> ' DEPARTMENT USE ONLY Data Z• 2�. O2 <br /> EMAP IN UNIT N FILE,ADDRESS; <br /> Aff PLAN DATED- <br /> icaMon Accepted By <br /> I <br /> peMion By Date Issued- nt nay <br /> un Inspection 6y Date______�Flnai InspecL'on By <br /> Date Date__ <br /> MENTSI CONDrTION9• p , <br /> NTNG ONLY: Alp# <br /> oAr�e <br /> %ODES FEE NFO AMOUNTREMMED CHECK# <br /> RECD BY DATE PERMR/SERVICE REQUEST# INVOICE <br /> wd2, sme Oo <br /> � AZ�� C-57 Letter of Authorization to sign permit_ Ervron�hmPnt a . �, <br />