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WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />.,, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />OCA 4 Z00°� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 458-3449 <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 />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />DAssessor's <br />WE? t Location , 5� j C++ OC' ^i16 �' S�. Cross Street L Y n VI City �-m66 (t ziip Parcel# I G -/ y� L) /, <br />PROPERTYOwner Pkjjj J Le-kr17n4r\ Address 7SZ? E� n�' aJ0 City f�Yt'r7CL6'2'' p Phone 1-i��'7 <br />C-57 Contractor � 7 fJ City 10o <br />Consultant! Sub Contractor �(;-� Address `z37 lai.l ISG City 5�.nLictl�tS•Z/S Phon"l�'�I�% <br />CAI <br />n <br />GIS Coordinates: X , Y , Township Range <br />Section <br />W RK TO BE PERFORMED: <br />EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />SOIL BORING # h 1 ' ii> > 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: <br />_ <br />Grout Specifications: <br />FEE INFO <br />COMMENTS: <br />CHECK # <br />REC'D BY <br />a <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />WELL CASING DIA �J� <br />Q <br />0 MONITORING <br />0 HOLLOW STEM <br />F ' <br />DIA. CF BOREHOLE � MULTIPt� CASINGS. � YES 0 NO <br />0 EXTRACTION <br />11 AIR HAMMER/DRIVEN <br />CASING THICKNESS_TYPE OF CASING: 0 STEEL 1] PVC 0 CTHER: <br />(� <br />0 VAPOR <br />0 MUD ROTARY <br />DEPTH OF GROUT SEAL E(+ �' TREMIE TYPE TO BE USED: 0 AUGERS '$'ROSE <br />(� <br />AIR SPARGE <br />;PUSH POINT <br />GRCUT SEAL PUMPED: [] Yes to (NOTE: M MUM FREE -FALL DEPTH IS 30') <br />CIL BORING <br />1] HAND AUGER <br />GROUT SPECIFICATIONS: (%l< �� ra �t /Y1L✓!� r t �t'���'S�`r -- <br />0 CTHER: <br />❑ OTHER <br />APPROX. BORING DEPTH 3O 1] BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />'COMMENTS:�'R 6 <br />n� ,,,�. o <br />1 � "" "'�- �'�' <br />CONDUCTOR CASING PROPOSED? / ✓� (if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMEN I NtxM1 I a. <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 Ordinanc , Rules nd,Regulations, and all applicable California State Laws. <br />Signed x l Title/Company <br />Print Name i G�VI 1 l I y] G Y1 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 4r �, e,C I <br />Application Accepted By Date Issued /U 1� �! Area �✓� <br />Grout Inspection By Date Final Inspection By Date__ _ <br />COMMENTS / CONDITIONS: <br />- <br />ACCOUNTING ONLY: <br />I <br />CODES <br />FEE INFO <br />EAID#PE REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT I SER VIC ST # <br />INVOICE <br />InI2 -41A, <br />n i'3-r/nn <br />C-57 WC= WAIVER C-57 Letter of Authorization to sign permit_ EncroacnmenT aoc_ - " - <br />