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F1 <br /> 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 DN , <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San'Joaquin County Public Health Services,Environmental Health <br /> Division. <br /> Assessor'HELL Location 2�0 \v �°� ^ S,C Cross Street 0 ar� - City �c^^�� zjp UQ Parcel# II <br /> PROPERTY Owner �� 2�- Address D J� D2Z City <br /> 104 eQ� zip�sr 3 b Phone# Z3 �I`l <br /> °�5 ,1 k tom_ � s8t� <br /> C�7 Contractors ` Address O C\�'�� City ' Zi P�� 3 Lic#�8 S1 S Phone# S 3 3 <br /> < O "\L k S-t City��r=Lic# - Phone# S 2 Z.�t l� <br /> Consultant/Sub Contractor Q wQ ��� ���� >Address �� \ <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> a NEW WELL/BORING P GEOPROBE,HYDROPUNCH,HAND-AU ER,DTHER`) d OVER-BORE <br /> @ SOIL BORING# <L PT \ -5 PRESSURE GROUT <br /> WELL# <br /> "Other: Grout Specifica,tions: <br /> COMMENTS: 0.� - l -� 3 p <br /> \1J\ c3- GO <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING p HOLLOW STEM DIA.OF BOREHOLE_?`�MULTIPLE CASINGS?j]YE 0 NO WELL CASING DIA: <br /> f}EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL a PVC. []OTHER: <br /> VAPOR .0 MUD ROTARY DEPTH OF GROUT SEAL 9, TREMIE TYPE TO BE USED:. 0 AUGERS HOSE <br /> p A A GE p PUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTEMA UM FREE-FALL DEPTH IS 301) <br /> SOIL BORIN ❑HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER; []OTHER APPROX.BORING DEPTH . r []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CQNDU-CTOR�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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina es,Rules and Regulations,and all applicable California State Laws. — <br /> O�F: <br /> Signed x oQ Me/Company <br /> J¢�Y�w <br /> Print Name Date- <br /> DEPARTMENT <br /> ateDEPA TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: l <br /> Date Issued Area <br /> Application Accepted By a.a : 1 ti- Date <br /> Grout Inspection By Date Final Inspection B <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE 1NFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST INVOICE <br /> so of 7�1 g-33 03y2 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> E0 30GJ NOO-IJ HiAIJ EEbE89b60Z 99:ET 100Z/8Z/Z0 <br />