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09:'25/2000 14: 35 20946634 .? FIFTH FLOOR P:;rE 0" <br /> !�`'--- WELL PERMIT APPLICATION FORM SITE <br /> JAN 1 9 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENV1,;i1jWj,�NjW >MENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplication is hereby made to San Joaquin County for a pemtlt to construct and/or install the work described. This application is made In compliance mth San <br /> Daquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Service.,Environmental Health Division. <br /> Assessor's <br /> FELL Location_ q-1Oc) W, 5c �. kk -(ZeLcross tstreet ` City la.c Zip 53 (o Parcel# 7-09 ZY0-2;4 <br /> ROPERTYOwner©In>?.Ks- S'-"CILVi.1 Address `T4OO W.sIzLtk CityTrz ziP1y3-4phone#209-'93k-- LI L_ <br /> -57 Contractor Sem c-TTtn,' Address_23 L�-L\J, W.^.� 2-' St Z " <br /> i ( `�' �f City S�+►�.k�v�Zip /Lic# Phone#Z"I Li 6S-ET I— <br /> onsultant i Sub Contractor �';O A elt-A s fo< Address_ �� C-I'cc✓t,c.�Xy-city ©�kk wkc# Phone# S/8-2.1'-1-?0 our <br /> IS Coordinates_X Y _ Township Range Section _ <br /> IORK TO BE PERFORMED- <br /> NEW WELL t BORING(CPT.GEOPROBE,HYOROPUNCH,HAND-AUGER.OTHER-) &,6STRUCTION(choose type below) <br /> D SOIL BORING# PVER-BORE <br /> D WELL# D PRESSURE GROUT <br /> ether: GROUT SPECIFICATION 04�,4- Canv-..ate Y- <br /> OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING D HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> EXTRACTION O AIR HAMMERJORIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC D OTHER: <br /> VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS OHOSE <br /> AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING O HAND AUGER GROUT SPECIFICATION <br /> OTHER: 0 OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES.list specifications here): <br /> OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ' CAL T E UNIT IV-[TECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIREDINSPECTIONS <br /> fined x Title/Company +- y / &s- � � i <br /> Pte/ �� 0.,.� Q� o � . Ssa<,a�., <br /> int Name {�L t/� �evt✓�a��c�5 Date-4 a Z. 1 <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED dO� 3 <br /> DEPARTMENT USE ONLY <br /> )plication Accepted By Date Issued 2 b Area <br /> -out-out lnspectlon By ' 'iN-A tni` Date 2 Final Inspection 8y ao__ Date <br /> astruction Inspection By Date <br /> DMMENTS/CONDrTIONS: 17TT1C121 �I- <br /> ACCOUNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK 9 REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> a o o,©oi�o C ► z3o/ sg# 01!), %;-I 0 <br /> C-57_ WC/WAIVER _ C-57 Letter of Authorization to sign permit Encroachment doc 9/12/00 <br />