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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 1 YEAR FROM DATE ISSUED <br /> pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application:s:Wade in gmpliarce wiL1 San <br /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Sernces.Envircumenlal Health Division. <br /> Assessor's <br /> LL Location 318' G.(,-Porn%n Sneer Cross Street 44-Ps,0-e ST- City SToc�'Ton ?;p 93-203 Parcel# /y9-o95- 1/ <br /> ROPERTY Owner Rol, f a�co Address 7%0( Ciry STockTh Zip 55207 Phone# C1o9) yCs-"25- <br /> C-57 Contractor T l,,;,,, 4,t on,for;a M Address ,2.-77 , ST f Ciry Fresnc Zip 97Zi Lic#<06/S9 Phone#SSS LL"-701/ <br /> tnsultant/Sub Contractor. 7�..;,,°,,, 1..1,0reTg, Address 24L7 fiesn0 3recr City Fresno Lic# Phone# (3-3-9)269--701/ <br /> GIS Coordinates:X ,Y .Township l A/orfA Range—j( Eosr .Section // <br /> ORK TO BE PERFORMED: <br /> EW W ELS//BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) I DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> tOWELL#_I ( fM w-/1 I PRESSURE GROUT <br /> her: Grout Specifications:: <br /> MMENTS: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES I NO WELL CASING DIAD <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS Sc1e4li Ya TYPE OF CASING: 0 STEEL I PVC 0 OTHER <br /> tSV0 MUD ROTARY DEPTH OF GROUT SEAL Al/r TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> IRk P PARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Am <br /> OTHER: 0 OTHER - APPROX.BORING DEPTH 75 r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? '(if YES.list specifications here): <br /> OMMENTS: we// w;/l 6e Ip l� ,/ r.,:/ G„ ,, .F"llew 7A i e0rie TO of <br /> G- olva r /e_ <br /> NOTE: OFFSIT 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 and Regulations, and all applicable California State Laws.. / <br /> Wed x -- 11 ��// Title/Company / �JIA (lJoC !✓�B�rS <br /> 11 Name 'lrr.A� ZYNSRI Date <br /> DEPARTMENT USE ONLY <br /> tE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> ticalion Accepted By Dale Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> truction Inspection By Dale <br /> MMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> L <br /> CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 7_ WC--WAIVER--- C-57 Letter of Authorization to sign Permit_Encroachment doc_ 9/27/00 <br />