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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 /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> plication 's 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 Ccunly Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Envircnmental Health Division. <br /> Assessor's <br /> ELL Location 323 A..,er:vn SLr" Cross Street Lo f .TT. ST. City ST el-&w Zip %5203 Parcel# /y9-095-Ob <br /> OPERTY Owner (+oL, FrQrco Address 7YOG Woo./$"core City--!LY E ron Zip 915707 Phone# C204) yLb-1lzZ.S <br /> i57Contractor r (t,oreln;,`e: Address .2527 Fresne Sr,�eT City—)!:, Zip 737.21 Liu Sob/ Phone# (EE4)265l-7ozl <br /> nsultant/Sub Contractor 7:,,l.,o L.,6er�r:« Address .2527 Fresno SLE" CityFresno Lic# Phone# 4M)2611'-70Z/ <br /> J <br /> GIS Coordinates:X ,Y .Township lJorrk Range 6 Eas7- Section <br /> RK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,6AN0.AUGE OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 2 CNA-s- . YA-0 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> her: Grout Specifications: <br /> MMENTS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> tONITORING 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 /> IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R SOIL BORING I HAND AUGER GROUT SPECIFICATIONS: <br /> �THER: 0 OTHER APPROX.BORING DEPTH /0 ' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> tereby certify that I have prepared this application and,that the work will be done in accordance with San Joaquin <br /> unty Or <br /> di <br /> n <br /> a <br /> nceRules and Regulations, and all applicable California State Laws. <br /> Ined x �r Title/Company / r IIJI�rr �4S <br /> nt Name -IF ,z Y/JS Kr Date oil /'Q�- '✓/� D/ <br /> DEPARTMENT USE ONLY <br /> 'TE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> tlication Accepted By Date Issued Area <br /> Grout Inspection By Dale Final Inspection By Date <br /> jillistruction Inspection By Date <br /> MMENTS I CONDITIONS: <br /> CCOUNTING ONLY: AID# FAQU <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />