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WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS -EHD ) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton , CA. , 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplieabon 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 /> oaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> � ,,tI Assessors <br /> YELL Location L1,20 /AC/h/C /JVE� Uf Cross street -Ed RrL Ay City :rmeKTbt.) Zip g O �Parcel# 0RZ- 3L0 - <br /> 'ROPERTY Owner ;?fMO IfAA/E'P,7 _Address /,jZ >� 7Vgt �TER $T. City 578eCTD4J Zip 9S1n9 Phone# .ZO$- H�8- SS75— <br /> e97 - <br /> :-57 Contractor YKW DR//1JVG Address /�O BOX dlL City /5LE7DAU Zip 9SLyl Uc# 71D a# Phone# 9/L - � � 7- W/oD <br /> :onsultant / Sub Contractor C'a4o0R EAR JH /LeN jAX.Addressj ` Sze� fr WLsr Pi slisCity ST0CY7De) Lic# Phone# 105- 13y-OS7Z <br /> Swrt S <br /> ;IS Coordinates: X . , Y., Township v?W Range G E Section <br /> VORK TO BE PERFORMED: DESTRUCTION (choose a below) <br /> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) 0 OVER-BORE <br /> 1] SOIL BORING # a PRESSURE GROUT <br /> (/JEH <br /> 'ify <br /> AT <br /> Other: Grout Specifications: �,� <br /> :OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS it <br /> MONITORING ,XNOLLOW STEM DIA. OF BOREHOLE 8 rt MULTIPLE CASINGS? U YES 'YNO WELL CASING DIA: _ <br /> ] EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS Selo , 40 TYPE OF CASING: O STEEL XPVC BOTHER, <br /> ] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL,_,ZLL. TREMIE TYPE TO BE USED: gAUGERS o HOSE <br /> 7 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 'Yes x No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> ] SOIL BORING aHAND AUGER GROUT SPECIFICATIONS:�i � •r lta�T <br /> OTHER: 0 OTHER APPROX. BORING DEPTH YS' BOLTED TRAFFIC BOX or 1] STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?�/ _ ( if YES, list specifications here): <br /> 'COMMENTS: [ R ec 6WEL4 <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 prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances , Rules and Regulations , and all applicable California State Laws . <br /> Signed x Title/Company <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED ' <br /> ` t/rJ_ v0O? Area <br /> Application Accepted By Date Issued /� 6 <br /> Inspection By Date <br /> Grout Inspection By <br /> Date Rnal <br /> Destruction Inspection By Date as 1 <br /> COMMENTS / CONDITIONS: S S <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DA E PERMIT / SERVICE REQUEST # INVOICE <br /> 36 <br /> p g so 27 z 2�3 33Zt <br /> AL +hM _ 'nn_ si L. _rmit Encroachment doc_ 9/27/00 <br />