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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION., <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH D!VlSION {RHS-EHD) <br /> 304 E. Weber,Third Floor, Stockton, CA., 9202 <br /> L (209) 468.3449 <br /> 4 -mow <br /> NDN-E2EFUNDABLE PERMIT EXPIRES 9 YEAR FROMDATE ISSUER application is made to compliance with San <br /> kpplicalion Is hereby made to San Joaquin County fflr a permit to construct andSerf <br /> erf J install Cl o work described. This app Assessors <br /> Joaquin County Development Title.Chapter 9-1115.3 and the Standards oo a�nKaaquin Caursty Public Health Services,Environmental Assessor's ENvisiors.s- 3 <br /> City.S�O Zip���_._.Parcel# <br /> NELL Location\`�1ak �C `�"� S� Cross Street 5T- jl <br /> Wle'A NJs.sa� 1y.,� w . �ce,�.v..'I aty S'r -zlp chane# y -OIR <br /> PROPERTY Owner Ca. Address i'`72�°1t7� Q>tib 1 -1 4 Obi <br /> '�S�e'F'Lp S 6`11 Uc#: Rhona# <br /> l ��� ��Z]�`� Address, 1� 4 <br /> Ct,T Contractor ? $Z"1 �1 <br /> Consultant/Sub Contractor <br /> to SSL L�- 1z, s � O 'S Clty '0�£ll-'Lic#Phone# tV <br /> ,Tawnshlp Range. SecBon <br /> 015 Coordinates:X Y <br /> WORK TO BE PERFOR ED• p DESTRUCTION(choose type below) <br /> IyEW WELL/BORING(CPT,GEOPROBE,}tYORQPIJNCH,HAND AUGER,OTNEIt') 0 OVER BORE <br /> a SOIL BORING# U PRESSURE GROUT <br /> Grout Specifications: { <br /> `Other: , S^�O C, c�ft,hni <br /> COMMENTS: <br /> S. �J <br /> nPE� OF WELL INSTAL TION GO STTiUGT10 SPECkFICATIONS NO. WELL CASING DIA:•: i <br /> �'�MULTIPLE CASINGS?[i YES ,Q <br /> �MONiTORING p HOLLOW STEM DIA.OF BOREHOti � TYPE OF CASING, Q STEL o PVC. 1]OTHER: <br /> it EXTRACTION p AIR HA.MMERIDRIVEN CASING THICKNESS�� TRCASI G, To BE USED:. a AUGERS p�HOSE <br /> E VAPOR 0 MUD PUSH POINT ROTARY <br /> GROU SEALOF RPUMED:L Uye q OTE. MAXIMUM FREE-FALL DEPTH 1S 30'} <br /> U AIR SPARGE 0 <br /> D SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: 130LTE[]TRAFFIC BOX or 0 STOVE PIPE <br /> aO-fHER���GTHER��._ APPROX.BORING DEPTH. 0 <br /> a <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 43 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 Son Joaquin <br /> County Ordinances Ryles and Reg I tions,and all applicable California Stat Laws. p <br /> w Titie company 4' • C.S i <br /> Signed x L� <br /> Print Name pEpARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> c Date Issued Zv Area <br /> Application Accepted BY 0Date <br /> Grout Inspectton By <br /> Date Ina[Inspection By <br /> Destructlon Inspection By ` ;! Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' BY DATE PERMIT!SERVICE REQUEST p INV4:110E <br /> Z <br /> C-$7 W _WAIVEC-57 Letter of Autho i tion sign permit—Encroachment doc 9/27/40 <br /> C {- <br /> E0 30Vd I! N007A HiJId EEV689b60Z 99:E1 Z60Zf8Z/Z13 <br />