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WELL PERMIT APPLICATION FOM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />MITIGATION <br />UNIT IV <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 />( Assessor's <br />HELL Location `�' ^J ^� S� • Cross Street oA� City <br />Zi Assessor's <br />Z Parcel# 1 3 S - <br />\�o\ W1 a�S��SL cr �5zo1 <br />PROPERTY Owner es W Address iy�� W c c e. �v .� � City S� �c IL��� Zip Phone# <br />I-- See E'n ,-L <br />C7 Contractor Va w ��`Z`�\���Address Qy`F City Zip S64a15T <br />)Lic#Z Phone# O 1 4 O� <br />cwt, r: CS <br />11 O I 1 ` S� Clt ��ckl Lic# Phone# 7-U c*, S 1;7-4 l� <br />Co�ns�ltant !Sub Contractor �s--��J�O �� cp.� Address Y <br />GIS Coordinates: X Y_ , Township Range Section <br />WORK TO BE PERFORMED: <br />[] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />(] SOIL BORING # <br />11 WELL# \Z\ <br />*Other; <br />COMMENTS: <br />'r ', a0'r- d, �� P <br />TYPE OF WELL <br />INSTALLATION TYPE <br />(! MONITORING <br />[I HOLLOW STEM <br />(] EXTRACTION <br />0 AIR HAMMERfDRIVEN <br />0 VAPOR <br />0 MUD ROTARY <br />0 AIR SPARGE [] PUSH POINT <br />j] SOIL BORING 0 HAND AUGER <br />0 OTHER: j] OTHER <br />*COMM <br />C.c­� <br />C. <br />0 DESTRUCTION (choose type below) <br />[] OVER -BORE <br />0 PRESSURE GROUT <br />CONSTRUCTION SPECIFICATIONS sl-jl— W O —V b �a-ll <br />DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES [] NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC [] OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS 0 HOSE <br />GROUT SEAL PUMPED: (] Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICA <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or []STOVEPIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />NOTE: OFFSITE BORINGS 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( Reg I tions, and all applicable California State Laws. j <br />Signed x C� Title/Company w 1 C �� � `' C S V <br />Print Name \��" rJ� � �y '� Date Z1 pZ <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By \ " v Date Issued V <br />Grout Inspection By Date U Final Inspection By <br />Destruction Inspection By —Date <br />COMMENTS 7 M?NDITIONS- <br />—Area <br />SITE <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />:CHECK#]REC' BYLDATEPERMIT/ <br />SERVICE REQUEST# <br />INVOICE <br />©c� <br />2- <br />C-57^ WC; WAIVER_ C-57 Letter of AuthoFittion sign permit_ Encroachment doc 9/e//00 <br />EJ 39`d N007.9 H1�I9 EEbE89b69Z 95 :EZ i9aZ/8Z/Z© <br />