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ENT <br /> 9ECEIVED WELL PERMIT APPLICATION FORM SITE <br /> APR 2 9 20(l? SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> UNIT IV <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental <br /> Health Division. <br /> 6loc.kCi bo"v%AA-fA 6-1 C4v-9% +-t, city5�.��-�O✓'t Zip Parcel# SQ.� o-T�o�-�e� <br /> NELL Location CL�.n►.al, {twrorw� + Wa bir Cross Street <br /> �1. J Zi Phone# <br /> PROPERTY Own�elr 5 Ge- 0._t+O�-�►°-A Address ie.r+city p X05 <br /> -57 Contractor VIV0V%Q. MC-• Address2m0 Alao Ave-.AV • City-i. ,o Zip1`t$ iic# 9L4 Ph-ot <br /> one#$10-$(�" le le <br /> 1G Z <br /> Con or t+Vtst ty5i«kfon Lic# Phone#Zo9-Z3�-OSlB <br /> Consultant/SubConUactor�a -�r�olo_Aie�,Zh�Address Ci✓• St< • I C� <br /> uIS Coordinates:X <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') <br /> 0 OVER-BORE <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z" MULTIPLE CASINGS?0 YES �O WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL g <br /> It TREMIE TYPE TO BE USED: 0 AUGERS NOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 911yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: (OTHER NrL. t t�t,�S� APPROX.BORING DEPTHStt- a�fac D <br /> CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> 'COMMENTS: PIno.SQ a(,tY�c't' D�S� <br /> j� I=v�v►�•oy�Vy�2y�}e�l S i•i-¢.. Assam-s5►,��-►ti-t" Iny dr o.K(i c• <br /> r i �• ► l 0. d r b wv.d w ofim+r a rv. 1�. <br /> NOTE: OFFSITE ORINGS 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 Regulatio , and all applicable California State Laws. ^ / f <br /> O 2� i Title/Company GKv So-rU• M 4 r. l O✓Ly*`� <br /> Signed x v <br /> Print Name AV I <br /> I�. UV D ook Date <br /> MT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued � 2 Area2o1 <br /> �; <br /> Application Accepted By Date_ <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> o �' �— �83��/ R l�2� Do a- 7o Z D q 4ff � <br /> a ( � <br /> t 9/27/00 <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br />