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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,Environmental Health Division. <br /> /nJ�_ �'�-^'.', �n )J _ Assessors <br /> ELL Location�QO(O E( ISI W R/ �R- Cross Street r_ VYa �ity�aILCA- Assessor's <br /> 2OPERTY Owner r r�� P� P�U_ V�Address /,t� (it,YJ�'G CityI I�aLG Zip�Phone# <br /> 37 Contraclo4j. 'kJ t"Cal1�tldreesssl2a —W .1/.otA t- <br /> onsultant l Sub Contractor uksll(D/UYCt� IlGyl Address207-O 6 • I4t' 54yie4City �A'4 Lic# Phone#6/f)*,33-7/613 <br /> IS Coordinates:X 'Y ,Township Range Section <br /> IORK TO BE PERFORMED: -L <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) yuESTRUCTION(choose type below) <br /> p SOIL BORING# W6VER-BORE <br /> WELL# a PRESSURE GROUT <br /> Other: Grout Specifications: <br /> :OMMENTS'DC56,yAUY1 RF MQ rLrfyYl✓/C WG(IS MW flANl�i MW���, an d AA Wy4 4"TD -V 14.S <br /> P fvUVtf OuD1�VrXlvv)Gl Gf,� s l (/104W(i t W 7' 0'�W jilt. <br /> TYPE OF WELL INSTALLATION TYPE ONSTRUCTIO PECIFICATIONS <br /> ]MONITORING H HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES a NO WELL CASING DIA: <br /> ]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC l]OTHER: <br /> VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: IJ AUGERS HOSE <br /> 3 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes l]No (NOTE:. MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or [I 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 /> 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 /> Mr Lcr?s <br /> Signed xIlinnrl�,t�pMla�- l7YtIGfI,I�('-'fllC, Title/Company <br /> P 'nt Name ✓"l V,dA cmfj IQ✓1 Date <br /> DEPARTMENT USE ONLY <br /> SIT MAP IN UNIT IV FILE,ADDRESS: �I ("-6 ( a <br /> WO PLAN DATED: TI A- 2 <br /> Applicatio ccepted By �/ , ` Date Issued 3a U Area <br /> Date O � O Final Inspection By Date (Q4QIX 2-s— <br /> Grout Inspection By Tz— <br /> Destruction Inspection By Date 247 Oj <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 /> C-57 WC -WAIVER C-57 Letter of Authorization tO sign permit_ Encroachment doc_ 9/27/00 <br />