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D <br /> WELL PERMIT APPLICATION FORM 3tTE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IATIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E . Weber, Third Floor, Stockton , CA. , 95202 3 <br /> (209) 468-3449 ro <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O <br /> application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Rr 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 /> / A Assessors <br /> YELL Location CV.2415 r acP _ Cross Street City Sfi cL<4✓ -. Zip 9S2 Parcel# OS / - 36o - oZ <br /> 'ROPERTYOwner Parme✓I 8LAddress City =-. � 'ip_ _Phone# <br /> ;-57 Contractor Gs n • 4 } J,- ; //•n Address qo c h( /?vu d City n,,I�r , .-&Zip 9Yr.r3 Lic0a�767 Phone# 12.S,'-. 3! I -ra c <br /> vid <br /> :onsultant / Sub ContractorL� n.Lrr L %e_.4 . Address /8Y, %ve . rWe fir. City J T �y Lic# Phone# :7 `!-�xr/6 <br /> stiifc L <br /> AS Coordinates: X , Y Township N Range C Section � <br /> VORK TO BE PERFORMED: _ <br /> tNEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER') B DESTRUCTION (choose type below) - <br /> ,SOIL BORING # OVER-BORE <br /> WELL # PRESSURE GROUT <br /> Other: Grout Specifications: <br /> 'OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORING HOLLOW STEM DIA. OF BOREHOLE !i " MULTIPLE CASINGS? BYES � NO WELL CASING DIA: ':7 " <br /> I EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESSSL4 �0 TYPE OF CASING: D STEEL APVC BOTHER: <br /> ] VAPOR B MUD ROTARY DPPTH OF GROUT SEAL ;.? ' 4 S7 TREMIE TYPE TO BE USED: $ AUGERS B HOSE <br /> I AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: B Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> jSOIL BORING BHAND AUGER GROUT SPECIFICATIONS: /Vee< GeeneAn � <br /> OTHER: BOTHER < <br />