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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> .31:. ,,E.1) Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ' <br /> r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Envirer.mental Health Division. <br /> WELL Location 300 5o,.Jh 61;form. ST e<T Cross Street raTc..<T7c S&«7Ci c Assessors <br /> T— ry _ 7ock7on tip yE263 Parcel#_y 9y-095-p/ <br /> PROPERTYOwner Mre'noe.' Address 214 W 5cn7T A Ci S <br /> h T kr zip 95763Phone# C2d91 Y�L-vys= <br /> � 57 Contractor T;,;z, Loo T Address 2s17 Fr o �7 T City Ficsno Zip Lic# JDL IS Phone# (559),1/8'-•io7_l <br /> Consultant/Sub Contractor_%,,,,„ •„ Ar,�er,.7o Address_ - .y F-cs�„ 5Drc <br /> T Ciry Fresro Lic# Phone4_r:SS9;1�S-70z1 <br /> GIS Coordinates:X ,Y ,Township ! A/o,7L Ranges �.•T Section !I <br /> WORK TO BE PERFORMED- <br /> 0 NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH, AND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# <br /> 0 WELL# Y 0 OVER-BORE <br /> 'Other: Grout Specifications: 0 PRESSURE GROUT <br /> OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPEDt;F <br /> E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING I HAND AUGER GROUT SPECIFICATIO <br /> 0 OTHER:_0 OTHER APPROX.BORING DEP0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ordi antes Rules and Regulations, and all applicable California State Laws. <br /> Sign edz t,.1 Title/Company -7D//4J/A)C /(49.s <br /> Print Name �M• Z 7/SSKI Date ,K� �E�j O / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRREPS: 2500,:56L)-/-}+ CEJ cA ( � r <br /> WORK PLAN DATED: /—�U p // <br /> Application Accepted By Date Issued Area�7 Z�O / Olo <br /> 3rout Inspection By Date Final Inspection By Date <br /> Jestruction Inspection By Date <br /> COMMENTS/CONDITIONS: /A/ ,; [? 002-5-3998 , L>ti <br /> ACCOUNTING ONLY: AID# 411 <br /> PE CODES FEE INFO AMOUNT!REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 20l .7 QZ 538 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 9/27/00 <br />