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FILF Y <br /> q WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGAUNIT IVTION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 / <br /> CI . ROW <br /> (209) 468-3449 � <br /> Ff <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O X� <br /> pplication 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 /> ,aquin County navnIn .nr Tine Chnoter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> C //yam,,, ,/ �r� _ Assessor's <br /> !ELL Locatlor_ 1&o� `mks. -`4 Z 3trleet z('41Cl.D)city Zip Parcel# !�I <br /> ROPERTY O4ContracGtor <br /> ,1� Address <br /> N I City=P � <br /> Zip� JLPhone# r I-57 Contreclo - Addres-s %L /,�J -rp Ci Lic# I Phone#� <br /> onsultant I Sh Addres ) Yl% S e I ogity efl Lic# Phone#C.�'I� 'O <br /> IS Coordinates:X_._ YA• H} T�- ----Range _Section�IA <br /> FORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> p SOIL BORIry,G# U OVER-BORE <br /> WELL#3(tNIN �, ✓n( g PRESSURE GROUT <br /> 7ther: Grout Specifications: G <br /> OMMENTS: zO CI I YI^eS <br /> m I no. 15 ' o <br /> YP OF WELL `IN�ST'ALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 / ' <br /> 'MONITORING ;U HOLLOW STEM DIA.OF BOREHOLE^'�LTIPLE CASINGS?[]YES YINQ _WELL CASING DIA:GII <br /> EXTRACTION /a AIR HAMMER/DRIVEN CASING THICKNESS U TYPE OF CASING: 0 ST EL f?,�fPVC N OTHER: <br /> I VAPOR g MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS g HOSE <br /> AIR SPARGE g PUSH POINT GROUT SIAL PUMPED: p Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VI'l <br /> -SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: I <br /> OTHER: 0 OTHER APPROX BORING DEPTH _ Z I BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 0 (if YES list specifications here): <br /> COMMENTS: I S t r O I'ti f 2I <br /> NOTE: OFFSITE BORINGS IkEQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations, and all applicable California State <br /> �Laws. <br /> 3ignedx pulb, Tille/Compan - f ✓CYSk S�1f-�WC <br /> h60 <br /> 'dnt Name rYl l� -� S�{��its IJ Date w <br /> �f <br /> DEPARTMENT USE <br /> ONLY }� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> •YORK PLAN DATED: 2- ' Z —b Z LOp o K -0 3-7-e 2- <br /> %pplicetion Accepted By Date Issued Area Al- <br /> -D 6 8 <br /> ;rout Inspection By Date Final Inspection By <br /> )estruction Inspection By !4Date <br /> :OMMENTS I CONDITIONS: O <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMfTTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 31 <br /> SIR <br /> # Q03/ Dg <br /> -57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />