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ua/L3/2061J 1_y:.15 - ^ "2094683433 FIFTH FLOOP, � <br /> PAGE 0_ <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E. Wever, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 I <br /> NOH-REFUNDAELE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> =nliGtien i;hereby made b San Jcapu-rn Ceunry for a permit to construct.and/or.,stall Ns work 4!"cripeo. This apptfda9cn r;mace ir:[mm�fia-ce wft;;Sa• <br /> :acuin County Development Title,Chapter S-11'5.3 and the Standards of San Jcaq.,i Caunt+Fu'^.tic <br /> Health Sevice�s,Esn3L•o�nmoePnyfarce!aJ#e':�;th�rr1'3 L81J1e�n-.ELL LocatioAa-e55or� ISeel CrossStee[ 5riry ' 2ip <br /> ^!lY <br /> RCPERTYCvmer Eo-r- AddressSZ)-7 S+ U+tf V� <br /> II�� 4�b City Tme:/ ZIp�_qSj]�phonex�09 R's$'7�$. <br /> •57 Contractor�_� L1i_�t:..r ACd;ass Olt`-�-,, /y,, �}T,t�' <br /> �1 / ZipJ�7[^t1LUcr _Phonem �o ; <br /> CnSultant,'Sub Contractor WY;pfr -� yes es <br /> .n Eal Address �.l E. lotl� "Lecity TlT.LG�_LJC(O I Phone# 1 <br /> — _l OG'iR3pozS� <br /> IS Ccordin _a. <br /> atas:X ,Y - .'c�xnship Ran e <br /> C Sac^on <br /> 'ORK TO BE PERFORMED. <br /> I <br /> NEW WELL BORIN CPT.GEOPRCBE.HYCROPUNCH.HAND-AUGER, OTHER'; <br /> 11SOiL BORING:.< , Q DES-RUCTICN.(chacse C,pe hely v) 4 <br /> 0 WELL" - (]OVER-SORE <br /> 7ther: PRESSURE GP.CL'T <br /> GROUT SFECIF(CATION <br /> OMMENTS: <br /> (PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING o HOLLOW STEM DIA.OF 30REHOLE — '+r, MULTIPLE CASINGS? YES c <br /> I) ®NO WELL CA,-INC D! <br /> A: <br /> EXTRACTION 0 A:R HAMMERKR?i=?i CASING THICKNESS &11W TYPE Or CASWC: EI STEEL d PVC d OTHER: �— <br /> VAFOP, Q MUD ROTARY DEPTH OF GROUT, SEA:, TREIhtIE TYPE TO cE USED: [)AUGERS <br /> IA 05E <br /> AIR SPARGE <br /> ..Q PUSH PCWT GROUT SIAL FU,l+.AED <br /> . !Yes es Q:vo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SGIL BORING 0 HANG AUGER GROUT SPECIF;OATION t\p n k <br /> THER: _R r p$TJVE pIpE <br /> Q`• r' -APPp.O.K-BORING D_PTH S__(7 7. _E)90LTED ::AFFiC 90X or <br /> CONDUCTOR CASING PROPCSEO? (a YES,lis[;peciEcatleas <br /> OMGIENTS: - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS tE <br /> iereby certify that I have prepared this application and that the work will be done in accordance with San Joaqu:r. <br /> ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> CALL THE UNIT IV INSPE OR 48 WORKING HRS IN ADVANCE FOR <br /> /BALL REQUIRED INSPECTIONS <br /> int Name r: a A 3-2. O I <br /> SITE MAP IN UNIT IV FILE ADDRESS !WORK PLAN DATED +W Ax6 30 r <br /> DEPARTMENT USE ONLY <br /> )pllcation Accepted By Date Issued •Z ^D ( Area <br /> :ut Inspection By Date Finaf inspection By Date <br /> nstr-prion Inspection By Date <br /> DMMENTS 1 CONDITIONS: <br /> ?OCOUNTING ONLY: <br /> L <br /> 'E CODE9 FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST O INVOICE % I <br /> 1 3 3286/ OOZ5(093 <br /> C-57__ WC/WAT_VER_ C-57 Letter of AuthoriZCticn to sign perms Encroachment do C_ 7/17/CG <br />