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WELL PERMIT APPLICATION •FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC H"E�AlC ��}1 UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISIOW(Of4T3Z MCE <br /> 304 E. Weber, Third Floor, Stoc r�. 85202 <br /> C a.4 o u (209) 468-3449���t��� PM 3: 37 C)&) , AJ � C(/ <br /> 0 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 Division. <br /> Assessor's <br /> NELL Location Z,�O �.��A.� (� `J} Cross Stree_ NoRT!•} city�v. � zip Parcel# 1 <br /> PROPERTY OwnerC�64,O 2Cl- Address d�(�� ti Z?- City_SL J7 1533 , Phone# <br /> C-57 Contractor V k V \\', _Address \D ��f' "�\� CityVk>^ ZipUc# Phone#R1 <br /> Consultant!Sub Contractor - Address �\' \ n� SIC City Phone#Z o <br /> GIS Coordinates:X 'Y Township Range Section <br /> PERFORMED: <br /> [ANEW WELy BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> []SOIL BORING# [)OVER-BORE <br /> 9 WELL# []PRESSURE GROUT <br /> *Other. Grout Specifications: <br /> COMMENTS' , a<r'c<C o.c Q� \ 1 '1 03 \-3a< \c-6p,-" 4-- <br /> TYPE-OF <br /> -TYPE OF WELL1 N TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA,OF BOREHOLE I�K MULTIPLE CASINGS?j]YES NN WELL CASING DIA: 1 <br /> EXTRACTION Q AIR HAM !DRIVEN CASING THICKNESS��b TYPE OF CASING: STEEL PVC. []OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: []AUGERS ra HOSE <br /> []AIR SPARGE p PUSH POINT GROUT SEAL PUMPED Ye i]No (NOTE: MAXIMUM FREE-FALL DEPT <br /> j]SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: N4.a--;t <br /> []OTHER: I]OTHER APPROX.BORING DEPTH . �J � U BOLTED TRAFFIC BOX r [ISTOVE PIPE <br /> r 0 CONDUCTOR CASING PROPOSED??0_(if YES,list specifications here): <br /> t3 <br /> *COMMENTS: D. oro '- <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 prepa ed this application and that the work will be done in accordance with San Joaquin <br /> County Ord! s, lea and egulations,and all applicable California State Laws. (� <br /> Tltle1Company G�l o \s} w-r" 5 <br /> Signed x �\ZZ-' <br /> Print Name �Q a n0� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z/O /V, <br /> WORK PLAN DATED: 1-17- O <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By ate <br /> *4—F <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMT REMITTED CHECK# R C'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1SoI AMOUNT ON (� -3• D035 <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc-AZ& 9/27/00 <br /> 60 3Jdd 6007A HiAIA EEVE89P60Z 99:E1 100Z/8Z/Z0 <br />