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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 t."*eber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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,Environmental Health Division. <br /> a 1 Assessor's <br /> NELL Location ��O C" k���` S- _Cross Street City Sfi D��-�t°i Zip 5 3S Parcel# 13 q - Z3n Z z <br /> City <br /> PROPERTY Owner�v G�� �b � Address a,)k 1-2' _ S�ilc lLta�. Zip�15�-�"► Phone#�Uq yg Z 197 3 <br /> �AgS'6q) C-s-t�Lzo`loi <br /> C 57 Contractor Address �JX t 1\�n City Zip Lic# Phone# °�\b X17 1 UO <br /> Consultant 1 Sub Contractor Gr_ Z���Q caQ �"t"to dress City Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> WgEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> WSOIL BORING# '1-- G P l .17-G t> 2- (}OVER-BORE <br /> []WELL# a PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: ':7x,i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES a NO WELL CASING DIA: <br /> a EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC []OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. p AUGERS a HOSE <br /> 0 AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: 0 Yes Il No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER; a OTHER APPROX.BORING DEPTH . 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: <br /> S,P¢_ -.J J��-��o. .. deo. AA S - ')--T')1 - <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 Ordinances Rules n Reg I tions,and all applicable Califomii�a State Laws. <br /> Signed x Title]Company <br /> (Zai ,��, �Lcnb�o„-,J.,,► Date 10 1 1� 41 <br /> Print Name DEPARTMENT USE ONLY —� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: O 0 6Lf'1"'� h <br /> WORK PLAN DATED: <br /> Application Accepted By. Date Issued V_IArea <br /> y <br /> Grout Inspection B <br /> \ _ Date 1 (� Final Inspection Ay '4 <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDfTIONS: <br /> RPECODES <br /> ;FEEIN <br /> AID# <br /> AMOUNT REMITTED TCH7ECK#71REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � /Lp/ C a� �S <br /> C-57^ WC -WAIVER,_ C-57 Letter of Authorization to sign permit,Encroachment doc 9/27/00 <br /> 60 30V(:e X100-3 H13I3 ££b£89VGOZ 99:£T 100Z/8Z/Z0 <br />