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WELL PERMIT APPLICATION FORM "SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 Is made in compliance with San <br /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> YELL <br /> YELL Location 2103 Ca T-IeY LuA 61,114D- Cross Street FiCRNKLIN ttV City fiTocICTOiJ Zip 95264 Parcel# <br /> 'ROPERTY Owner-S NnI r2R6 Address QL'(.)'Cx ( 9 I?C6 City SX'(•Lln/ Zip4521p9 Phone# {; <br /> -57 Contractor (.Ak-Ai)E ZMIL4NGAddress G121:L.6City C�vR(byA ZipcL5-i42Lic# Phone# <br /> crFb � <br /> :onsultant/Sub Contractor � EKA)f}'�U/�f(�Address ?ihl-q KII 0404 010City C�DRQNA Lic# PhoneWjA1 L (ol—x}00 <br /> SkITE too <br /> ;IS Coordinates:X ,Y - ,Township Range action_ <br /> YORK TO BE PERFORMED: <br /> ]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> Q SOIL BORING# C OVER-BORE <br /> lJ WELL# J PRESSURE GROUT <br /> Other: Grout Specifications: <br /> :OMMENTS: - <br /> 'YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS d <br /> MONITORING n HOLLOW STEM DIA.OF BOREHOLE_ -Lcl MULTIPLE CASINGS?Q YES 0 NO WELL CASING DIA:X <br /> ]EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS VPE OF CASING: p STEEL []PVC U OTHER: <br /> ]VAPOR O MUD ROTARY DEPTH OF GROUT SEALJI' 3�/IS6 TREMIE TYPE TO BE USED: O AUGERS Q HOSE <br /> ]AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes�T00 No ( OTE: MAXIMU FREE- ALL PTH IS 30'))/ <br /> ]SOIL BORING HAND AUGER GROUT SPECIFICATIONS: Nl///� O - " <br /> OTHER:P,E2aM�2 0 OTHER APPROX.BORING DEPTH 0 LTED TRAFFIC BOX or H STOVE P <br /> ! CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> �7dr7� <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 that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> county Ordi ances,, Rules and Regulations, and all applicable California State Laws. <br /> Signedx J//'' ,A,--// Titie/Company SiAFIf 2ZS Cc4z Inlr EKn]frT1�N�h� <br /> Print Name SFi Z6 L�4W6 Date ��2 / . <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED' 2 <br /> Application Accepted By Date Issued �16 <br /> l Area D� <br /> Grout Inspection By - Date Final Inspection By Date � <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# terve <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> p'L W� 585312 !3 sRse <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />