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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 E. Weber, Third Floor, Stockton, CA., 95202 . . <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> plication 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Enironmental Health Division. <br /> I,, n ' ✓Gt p Assessor's <br /> ELL Location 2 p1&oG El f—Akio' o fes- Cross Street )1 City rQ Zip ,5304 Parcel# <br /> tOPERTY Ownertddress AlL City �fT �30�"'ZipPhone# <br /> cGt.� <br /> 57 Contractor Cl2S 0& Dnl IMG Address U-n city Ed,0ZipQ5742L1c#717jbphone# 916-639-116? <br /> )nsultant/Sub Contractor UES C0rPVr6(-0M Address ZOZO F• ISf S-faf1f City�P60 Lia# Phone# 71-433-7bt5 <br /> '.S Coordinates:X ,Y ,Township Range Section <br /> ORK TO BE PERFORMED: / <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a'DESTRUCTION(cf erose type below) <br /> 0 SOIL BORING# VER-BORE <br /> 0 W ELL# 1 a <br /> >ther: Grout Sp-ercifications: PRESSURE GROUT <br /> I <br /> OMMENTS' Sfy( {10VIOG D !!rU✓IfIGI �GGI w� l f/fh4 P GL6 /5y S Gel a rNC�/t 4 <br /> 3 � f�°[vv✓�� � <br /> YPE OF WE L IN ALLATION TYPE CONSTRUCTION SPECIFIC, ONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:_ <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:. MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> I OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <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 Ordinances, Rules and Regulations, and Gall applicable California State Laws. <br /> 7 <br /> /I/.1 / �.C/��IINVL/a / /�H�7�Title/Company 1'. <br /> Signed x /y <br /> ?rint Nama ���� Co n �Qn Date 3 /DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I o G � L—( Ll <br /> WORK PLAN DATED: <br /> Application Accepted By U�� I C�`� Date Issued 3/�QDate %5L <br /> aGrout Inspection By (Q � Date SCZ Final Inspection By <br /> I ) <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> (�� I � - 3 6 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />