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LEAPT <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ;�z• 2NVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> E <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DFr <br /> %pplication 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 /> Joaquin County Development Title,Chap(,er 9-1115.3 and the Standards of Sari Joaquin County Public Health Services,Environmental Health Division. <br /> tt,..r.sN SNc1.2 ��� Z 4 t- W\dx- Fr) Assessor'sNELLLocation �..Qkw—A\\e -RA, o 14! o Cross Street NtfAV S'k�City �elS� Zip 1533 Parcel# <br /> rG0 W okd. 1 .rr*C'_i..y <br /> PROPERTY Owner Address pD 13�� I4 ZZ Cirym tV. Z' 533 phone# Z��-L )�) <br /> C•57 Contractor t Nil\ �t/l'���, I' Address Q� Q 0� City1- N� k 7/Zip_j 4 S1I Llc*PZ' -+Phone# -1 <br /> Consultant/Sub ContractorC7C.l�( CAddrestid �- CityVc# Phone#_ <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> $NEW WELL/BORING(CPT9�a(G <br /> HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> # Ce p ro Q.-k� 0 OVER-BORE <br /> Q WELL# PRESSURE GROUT <br /> 'Other. Grout Speclfications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES J NO WELL CASING DIA: <br /> I]EXTRACTION 11 AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING: U STEEL D PVC. []OTHER: <br /> 1]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED: p AUGERS 1]HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 1 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 2 SOIL BORING HAND AUGER GROUT SPECIFICATIONS: A <br /> a OTHER:_D OTHER APPROX.BORING DEPTH . � _[]BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> `COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance,Ri s 4ryd Regulations,and all applicable California State Laws. <br /> Signed xfx-1 1 l \ Titie/Company �'r`SW CQ_Z <br /> Print Name \�s�`^-��r���Q� -�,r'J`a`�`4'^) --Date 3 Z 1 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: o N. <br /> WORK PLAN DATED: N' /5"•0/. 04 ekiZZ•OJl�• <br /> Application Accepted By Date Issued [ Area v�w <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: 3'L 2.0� S•Jb•O l <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> L$/ -'i3 /.s-3z3 suitDL53 <br /> C-57WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment do c 9/ 1 <br /> L � Y <br /> 60 39Vd X100-IJ HiAId EEVE89VGOZ 99:EZ 100Z/8Z/Z0 <br />