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PAYIV;` WELL PERMIT APPLICATION FORM SITE <br /> DECEIVE' <br /> TION <br /> SPR 2 9200 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> SAN JOAQUIN COUNTY 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PUBLIC AL <br /> TH SE130CES <br /> EMIRONMENHEALIHOMSI (209) 468-3449 <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 /> !oaquin County Development Title,Chappter�9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> bloc-It'4 : lbov-= 67 StaKISlAItil� Assessor's 1� I f <br /> NELLLocation Cke.KK.a.1,Cra.h*o + Wa-6s-v- Cross Street City SIOeJC{pr1 Zip Parcel#_SQ.Q O�.T*roe-kVL r <br /> 'ROPERTYOwner 5!-e. 0.*&-r.vlo_01 Address City Zip Phone# <br /> `, <br /> 57 Contractor VtYOY12yG T-Y% Address 2-110 A410.1"- ;' AVe.• City ro Zip1`{S �oS <br /> *jLic# 9Z-4 Phone#$10-$(,6-467-6 <br /> Corr or e►r� l88 Fr•�Kl� WQ.st <br /> ;onsultant/Sub Contractor S-tc . I City <br /> , 5occ+,Dr► Lic# Phone#,ZO'1-13•�-O$!8 <br /> 3IS Coordinates:X 'Y Township Range Section <br /> VORK TO BE PERFORMED: <br /> ?iITEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other: Grout Specifications: <br /> :OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING D HOLLOW STEM DIA.OF BOREHOLE 22-" MULTIPLE CASINGS?0 YES 9/NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: D STEEL 0 PVC D OTHER: <br /> VAPOR 0 MUD ROTARY Dt PTH OF GROUT SEAL Nh TREMIE TYPE TO BE USED: D AUGERS N/HOSE <br /> AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: ff"Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 401L BORING 0 HAND AUGER GROUT SPECIFICATIONS: `' <br /> OTHER: VOTHERDir L,.t ,5.4 APPROX.BORING DEPTH14-4- o. ac 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> It <br /> NOTE: <br /> CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> ;OMMENTS: Pkoso. I EKVivo11w�2N}al Si-I-a. /�SS�-SSw«n"� : �ydra.►tilic. , d'rY�cE- Dtti51�. <br /> [- <br /> NOTE: OFFSITE ErORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, nd all applicable California State Laws. <br /> gnedx 2)c� t Title/Company QY',!• MQ r.��• C ov���'• <br /> int Name Dav W 00 ok Date <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> /ORK PLAN DATED/: ' � <br /> )plication Accepted By �C.�kt�`p �Q <br /> Date Issued /D2 Area <br /> rout Inspection By Date Final Inspection By Date <br /> sstruction Inspection By Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> 3E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> n,n-r,nn <br />