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RECEIVE'---) WELL PERMIT APPLICATION FORM SITE <br /> APR 2 9 200 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> SAN JUAUUIN COUNTY <br /> PUBLIC HEALTH SERVICE`S 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENTAL HU41H ON (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 wor'R described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 8164.c l*. bouAv%4..A b At4roAssessor's 11 I <br /> NELL Location Gkwnn¢1. U PZF. VJQ6ar Cross Street City S�D�k.(-O✓► Zip Parcel# 3eA <br /> ?ROPERTYOwner Se-f— 0."It'O�c.ti►a-� Address City Zip Phone# <br /> `+ Sex+ *05 <br /> 57 Contractor VIYONQ.IG T_Y►C AddressZ�1� A�0.wly Ave-. Cityl..a�+ wo ZipjjS�tic# 9L4 Phone#510-$(8-ileT(o <br /> Con or wr-t'k /$8 Fr.►nic. West "� <br /> Consultant/Sub Contractor 'Ta-e-hrtiologjey,=„G ✓ <br /> •Address C, . tt <br /> � s . I Citv�+ock+on Lic# Phone#2.01-2.3^4-0$/8 <br /> 31S Coordinates:X 'Y Township Range Section <br /> NO RK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> -OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING 0 HOLLOW STEM DIA_OF BOREHOLE 22-” MULTIPLE CASINGS? 0 YES R/NO WELL CASING DIA: <br /> ]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: 0 AUGERS J(HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: B'Sres 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: `� <br /> ]OTHER: VOTHERD►rL&t PKs4 APPROX.BORING DEPTHSu- 0AMC 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r}� <br /> CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> COMMENTS: PInaSe I�. Ev%Viyoy1W q.,%+o t Du.s1\ <br /> NOTE: OFFSITE EYORINGS 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 /> 3ounty Ordinances, Rules and Regulations, and II applicable California State Laws. <br /> Signed x }� Title/Company en\Jc��V Iy►q/y C 0 ydo <br /> Tint Name V6_V 1� V. \N D od Date 4— /�n7 <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: <br /> NORK PLAN DATED: <br /> application Accepted By /d'��'�-�-C�C Date Issued yArea d 6A, <br /> 3rout Inspection By Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: 1 FAC <br /> AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> f-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />