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I <br /> PAYMEN WELL PERMIT APPLICATION FORM SITE <br /> RECEIVED MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> APR 2 9 2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> SAN JOAQUIN COUN 1 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PUBLIC HEALTH SEl1VICi`' (209) 468-3449 <br /> �NVIROWENTAI Flt Al l u fll�r <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> F, blic- Works PZ'�9 k-t-of- t,Jv�� Assessor's / <br /> HELL Location tJ�bc r,Ch"np%e l Mi.�.tr� Cgra71 ross Street City Stock }-o V% Zip Parcel#_�tt,2 o.�r.-,e-kl <br /> 5}an islwo�.S�Ptwr o ro. <br /> PROPERTYOwner 6e-e- 0-*01,c -QJ Address CityZip Phho�one# <br /> C-57 Contractor G f cy- ,, DA.Jh q Address . i City` 7 ILic#G 7 Pho�s/ S <br /> Con or - -4, !88 Fr•.Kk_ West <br /> 3onsultant/Sub Contractor Te-c A o o iet, IrnG•Address Ci✓. S-tt. 2 City�{oc.k+4m Lic# Phone#.Z09-Z3-4-O$!8 <br /> 3IS Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> PRESSURE GROUT <br /> 0Other: 0 WELL# Grout Specifications: <br /> 'OMMENTS: <br /> Yp- <br /> {- / <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C` l 6� <br /> 1 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2-++ MULTIPLE CASINGS? DYES R/NO WELL CASING DIA: <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> j VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Nh TREMIE TYPE TO BE USED: 0 AUGERS FI-10SE <br /> J/AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: R"Yes flNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> !OTHER: [OTHER Dir L,. I�,,t,s4 APPROX.BORING DEPTHS" 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �}. CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> :;OMMENTS: Pboso- E1nViecymey y%+o-1 Si+R- ASSe-SSYN�Y1"t �yatrout�i<.� oCIYQc-f P"S�% <br /> iooei i t MKO( rowhd wo,-t&V atom. 1c. Er`croac 4.w...w+ a_,rvv.i t- FEa� 1 01. <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 /> 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 Regulati ns, and all applicable California State Laws. / <br /> igned x 1/ + Title/Company Ev%\j i YD w.a-v � U t G.�S (_�iUY <br /> -int Name DAV tal Y • VV m e>o1, Date 8 O 2 <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> /ORK PLAN DATED: <br /> )plication Accepted BY44k� Date Issued / /� Area <br /> rout Inspection By Date Final Inspection By Date <br /> astruction Inspection By Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br />