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Pr <br /> 3:04 2094683433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> HEALTHIC r�Ti ION <br /> SN VIIRONMENTTAL HEA THOAQUIN COUNTY LDIVIS ON (PHSREHD)S Ai,. /Sn <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 1 <br /> (209) 468-3449 ENV/R0, 710pp <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMlTg'pc r g T <br /> application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in mpiwH,,�uulh�5an <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Dlwsli <br /> �- Assessor's <br /> 'HELL Location <br /> Z-IIGy(y �l. (LA,aCHa Cross Street City 11LACx Zlp Parcel# <br /> PROPERTYOwner It-ICHs.15N '7c-- =r Address <br /> City tip Phone# <br /> a-57 Contractor Address city�c Zip UdF Phone# <br /> ConsulgM/Sub Contractor ❑c„hl 4L�I.ticA[tdress %nJ! . Ec.t p&" City <br /> /_'28L� Ud{ Phona# 0"'Y-Y'r�012.3 <br /> GIS Coordinates:X- .Y ,Township Range Section <br /> WORK TO BE PERFORMED_ <br /> p NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH, D-AUG OTHER-) p DESTRUCTION(choose type below) <br /> jj SOIL BORING# HA� I Tltr ' �[ i {)-/k-� 0 OVER-BORE <br /> 0 WELL# � 0 PRESSURE GROUT <br /> 'Other- Grout Specifications: r �5 <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?BYES ONO WELL CASING DIA:_ <br /> D EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC D OTHER- <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or p 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 N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I 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 all applicable California State Laws. <br /> Signed x t'" 'V /AS A-`?� ` ski 1 F-1-7 Isle ICompany N ` -�-L-- <br /> PnntName ��-s,ti Lf jc-k— Dam <br /> DEPARTMENTUSE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: a l x i G <br /> WORK PLAN DATED: I D ;Lb o d <br /> Application Accepted By Date IssuedAreal <br /> Grout Inspectlon By Date t b Final Inspection By Date r <br /> Destruction Inspection ey Date <br /> i <br /> COMMENTS 1 CONDITIONS: - <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 2� () i IT � 3u <br /> C-57! WC=WAIVER,_ C-57 Letter of Authorization to sign permit_Encroachment doc.— 9/27/00 <br />