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r <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. Weber, Third Floor, Stockton, CA., 85202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <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 qie Standards o San Joaquin County Public Health Services,Environmental Health Division. <br /> o r Assessor's <br /> HELL Location Cross street CI m ane c w Zip q Parcel# <br /> PROPERTY Owner Add r , City �Y�Y��Q Ca Zip LS 3 3bPhone# ?! - LI) <br /> `1 t%k'- Y °1S(.y► '1Z,ogoA <br /> C-57 Contractor V a W _rj_A' �'L'& Address QLic# Phone#OI 1%.-1-1-1 <br /> Consultant/Sub Contractor G_%.A1\o,-,\e%Q2a+m,,Acfdress_;�G) '}}`L 7 St City nnV 4 Sf'•Lic# — Phone# Z\A S'L2`I AI <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 11 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> ii SOIL BORING# (J OVER-BORE <br /> WELL# PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: Ste. W'34- 10 O l a 30) o <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSMONITORING [I f_ <br /> p HOLLOW <br /> EXTRACTION n A R HAM ER/DRIVEN C SING BTOMULTIPLE <br /> THICKNESS TYPLE OF CA Ii ��i 1 61- <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREM ]HOSE <br /> a AIR SPARGE 1]PUSH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE; 1S 30') <br /> 11 SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: �!( <br /> a OTHER; 11 OTHER APPROX.BORING DEPTH . D � ! 1 �q 'IPE <br /> \, CONDUCTOR CASING PROPOSED?—�—(I JJ j I <br /> `COMMENTS: � Q �/V r-1c�P�dn v���� C"� <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin n ufe d gulations,and all applicable California State Laws. <br /> Signed x <br /> Print Name \tea ' �� A J v�/ Date + - 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: v <br /> Application Accepted By r Date Issued / �2- Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATEPERMIT/SERVICER ST# INVOICE <br /> ��i �� �� /3 516 Ii 6�6� <br /> C-57-___ WC;WAIVER C-57 Le of Authorization to sign permit Enaflbachment docs 9/27/00 1uv <br /> CO 3Jdd ND07J HIAIA EEVE89PSOZ 99:EZ Z00Z/9Z/Z0 <br />