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1 <br /> t <br /> WELL PERMIT APPLICATION FORM <br /> i fr <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> MITIGATION <br /> I ENVIRONMENTAL HEALTH DIVISION PHS-EHD - (�( <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 rt O '9 20"ti <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DPp,Vlp0-NM NT F1; <br /> Dplieation is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application'I., 'dij#3z Qji With San <br /> )aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health is n. <br /> Dp 1 Assessor's <br /> ELL Location 2103 C :�^Vr C" U\Qct Cross Street A,r, Dcity `J6ck\ a Zip X15204 Parcel#017.3-Ov,`-0;-q <br /> ,/ ,2 ;�c.. /0 Z--� Phoneir �y-'J lits <br /> ROPERTY Owne Aw.Q � �7 Address 35�� City _Zip <br /> kLlld o 74io <br /> -57Contractor �Jc_ 2 Address 302 0to 0�rck� Zip!3742 Lic# Phone# 916 63Y 110 <br /> c r 1 �y '41.k. _Lic# Phone# i16 &di c400 <br /> onsultant/Sub Contractor -)f cel \^ eci.^ .ov. Address 3orl K, Pu:\ City_ <br /> Coordinates:X ,Y - ,Township Range Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> U,SOIL BORING If 1 VER-BORE <br /> WELL# 1 ` H PRESSURE GROUT <br /> 'cher: � <br /> Grout Specifications: W(\ �un fMA btn� .L mnGe Ccs\ <br /> )MMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE�J ��MULTIPLE CASINGS?a YES b4O /WELL CASING DIA:-6_ <br /> EXTRACTION H AIR HAMMERIDRIVEN CASING THICKNESS 'a 40 TYPE OF CASING: H STEEL t�4C Jn OTHER: <br /> VAPOR ()MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q'AUGERS p HOSE <br /> AIR SPARGE H PUSH POINT GROUT SEAL PUMPED: H Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING U HAND AUGER GROUT SPECIFICATIONS: 2(b-^\Nn4en.^y `ien����c. m�:"\� ,,Q <br /> J <br /> OTHER: H OTHER APPROX.BORING DEPTH 6c`0 6 BOLTED TRAFFIC BOX or H STOVE PIPE <br /> n 11 11 CONDUCTOR CASING PROPOSED?�_(if YES,list specifications here): <br /> :OMMENTS: 2 <'i%Yr0.l,�'1 lu' 1�` 'u c, �2 CIP""J '4�G(. E-10-1 'F EW-2 <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 /> hereby certify tha I have pr pared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinan e Rups f1d egulations, and all applicable California State Law1s. ` <br /> ignedx Title/Company S Yk �er\t� / ""CoQ In�r•raROn;�1/_ <br /> -/" )Cy,'J/ <br /> 'dnt Name I.hIL11YL ' AQ Date _ <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: O ' <br /> YORK PLAN DATED: Z O Cifj0 <br /> pplication Accepted By Date Issued r Area <br /> :rout Inspection By 7W I S Date 3� 'D5 Final Inspection Date S— <br /> Destruction Inspection By A ate q-.7-6-5 <br /> ��TTTT'"` �v�v <br /> OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNTREMITTED CHECKS REC'D8Y DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ;7 w b ba ' 1 8 v9 s SIR# 13 <br /> :-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc A 9/27/00 <br />