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G 720 <br /> WELL PERMIT APPLICATION FORM d, <br /> • /,A, M MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT A <br /> 304 E Weber, Third Floor, Sto4ton, CA., 95202 <br /> (209) 488-344 011�;r <br /> NON-REFUNDABLE PERMIT EXPIRES i I FAR FROM DATE ISSUED <br /> AppiicaLon Is hereby made to San Joaquin County for a permit to construct and/or install the work described This application Is-made In campiiance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin rCounty Public Health Services Environmental Health Division <br /> roiDow <br /> NELL LacatlonQ;&, � S El ,Di�_�i. Cross StreetrI `' 3 157, Lay Zip Pa cel#nr's <br /> PROPERTY OwnerrL �j �- jP] Address ��N �f rUUp h CityN Z1p 5-Z0ZPhone# <br /> /G <br />:-57 Contractor—i4Dr,ll� L AddressTbAp)(41 Ci zip , Lic#-12ngp4hane# �5-7-Y)CID <br />:onsultant/Sub Contractor ELIC E I i'L Address �Z85 lLo AreCity !`�i Lac# DZz Phor7e# fall j/D <br /> SIS ordinates_X Y Township Ran Section <br /> Pt,anCl Grp rdrwx ,v <br /> t]RK TO BE PERIFC E <br /> I NEW WELL I BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION (choose type below} <br /> Q SOIL BORING# IrOVER-BORE <br /> ELL# <br /> Other- o Spec cations <br />:OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING []HOLLOW STEM DIA OF BOREHOLE ULTIPLE CASINGS'?j]YES 0 NO WELL CASING OIA <br /> EXTFZACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 1]STEEL I]PVC q OTHER <br /> V R Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS j]HOSE <br /> Al !ARGE p PUSH POINT GROUT SEAL PUMPED q Yes p No (NOTE MAXIMUM FREE-FALi DEPTH IS 3a,) <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> OTHER 1]OTHER APPROX BORING DEPTi-! I j]BOLTED TRAFFIC BOX ar STOVE PIPE <br /> CONDUCTOR CASING PROPOS O7 (If YES, Iistspecifications here) <br />:QMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN AD ANCE FOR ALL REQUIRED INSPECTIONS <br /> iereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> ounty Ordl ancefs!,, Rules <br /> and Regulations,and all applicable California State Law/ss.. <br /> fined z /)L—Voa Title/Compan �," '`' q,74�l <br /> int Name 5u /;-�O/s—, Date <br /> DEPARTMENT USE 10 i_Y <br /> ITE MAP IN UNIT IV FILE, ADDRESS: ..7• S# '� Gd <br />►ORK PLAN DATED: 3 '2. —0 <br />?phcatlon Accepted By Date Issued S 2. 2- <br /> out Inspection By Date Final Inspection By Date <br /> istruction Inspection By to <br /> 3MMENTS/CONDITIONS <br />�C TING ONLY AID# FArU <br />)E CODES FEE INFO AMOUNT REMITTED CHECK# RECZ BY DATE PERMIT/SERVICE REQUEST# INVOICE <br />-57 V WC -WAIVED AdA C-57 Letter" of Authorization to sign perrnrt Encroachment doc 9/27/00 <br />