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1 <br /> WELL PERMIT APPLICATION FORM SITE <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ppliration 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 /> oaquin County Development Title.Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> LL Location 300 .So..ip 6(,-forr,;., ST eeT Cross Street taFa..,Tic SF.JCiry S7ock Ton Zip Assessor's <br /> 95263 Parcel# /yq-09S-O/ <br /> ROPERTYOwner Mrcwot: b. O/;or.,ca Address %34 w. Sco7T. r/vuwe City Sro lion Zip 5263Phone#_ Cd69) YGL-v9� <br /> -57 Contractor "1,,,T,, Address_ 2527 Fr 51-.,,:r City--F 6sn0Zip 3 Z/ Lic# f%/S Phone#(SS9),16B=7o21 <br /> ,onsultant I Sub Contractor pabor.7or;cs Address 1527 Fresno STrceT Ciry Fresno Lic# Phone# C559)21 -70Zl <br /> GIS Coordinates:X ,Y ,Township / Algn& Range GE:T Section <br /> ORK TO BE PERFORMED: <br /> Iff NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH AND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# !/ (NA-r - #,4-Y 1 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> her: Grout Specifications: <br /> OMMENTS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 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 PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING I HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: fl OTHER APPROX.BORING DEPTH 70 ' ,0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ' (if YES,list specifications here): <br /> OMMENTS: <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 /> tereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> unty Ordinances RUIeS and Regulations, and all applicable Californian State Laws. <br /> nedz '� /G✓�/ <br /> Title/Company_ U��G 1449.S <br /> nl Name • KJWJ Z yNsK► fF�o <br /> Date <br /> DEPARTMENT USE ONLY <br /> 'TE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> location Accepted By Dale Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> strucfion Inspection By Dale <br /> MMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# RE C'D BY DATE ]PERFMIT/ RVICE REQUEST# INVOICE <br /> 57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />