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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 952.42 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> #pplication 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� Sin k c Assessor's 131-I L t- I D <br /> NELL Location (0 0 N. c5o m JoAq u i+s 5t. Cross Street o y-k Srf. City t v% Zip`}5202 Parcel# 1341-14pi- 11 <br /> 3ROPERTYdwnerDavi MaV1ANHc Wari34Nwa <br /> Ci±iAk _ovjto. f a%.R. Zip $ O Phone#701- 5-iS--1,518 <br /> _21id Ad-,,-Is AV&- SanIff X05 <br /> 57 Contractor Uiyon-Ly- rule_. Address City. ^Kotra Zip`�T$7 ic# R2-+ Phone#SIO-548-7f.44- <br /> C-ev%alor E6Ar'1k 1156 FrNa.Kk Wail f <br /> .,ons /Sub Contractor T��k n a l og i¢S. TKC.Address C i r., Sita- I____ city_s�oC �onLiC# Phone#2.01-Z�`!-OSI$ <br /> .31S Coordinates:X Y Township Range Section <br /> +YORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HANO-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> a SOIL BORING# [I OVER-BORE <br /> o WELL# n PRESSURE GROUT <br /> Other: Grout Specifications: <br /> MMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING [I HOLLOW STEM DIA.OF BOREHOLE .Z` MULTIPLE CASINGS?1]YES W10 WELL CASING,DIA <br /> I EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: p STEEL [I PVC a OTHER: <br /> 1 VAPOR MUD ROTARY DE PTH OF GROUT SEAL 1u A TREMIE TYPE TO BE USED. []AUGERS WAbSE <br /> AIR SPARGE la PUSH POINT GROUT SEAL PUMPED: les p No (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30') <br /> r9OIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> I OTHER: 5(OTHERQi✓tc-t pAJA APPROX.BORING DEPTH )5':j O' d BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> F 1 C NO CTOR CASING PROPOSED? N A (if YES,list specifications here): <br /> 'COMMENTS: - 1 <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San .Joaquin <br /> �ounty Ordina es, R s an 3 R uiations, and all applicable California State Laws. <br /> Signed x y TitielCompany d�l�.� >I�G� <br /> 'Tint Name ! LLZZ Date .]r � Z <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADD E S: �Q C <br /> `IVORK PLAN DATED: (0 5 a f <br /> Application Accepted By Date Issued 1 Z Area 9 v <br /> grout Inspection By Date b « D Zr Final Inspection By Date <br /> ]estruction Inspection By Date ll <br /> COMMENTS/CONDITIONS d t I rrk <br /> t i.. e. i <br /> 11 <br /> ACCOUNTING ONLY, AID# FAC <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> t-°!D 1 `� S LI b 3065 <br /> C-57 WC WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 4/27/00 <br />