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D 'V <br /> ,��nn F-ED <br /> WELL PERMIT APPLICATION FORM <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., 95202 D� <br /> (209) 468-3449 �� /" R• <br /> ON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATIE ISSUED �� <br /> plication Is hereby made to San Joaquin County for a permit to construct andlor Install the work described This application Is made in compliance with San <br /> aquin County nAUPlnnmanf TiuA Chanter 9-1115 3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division <br /> Assessor's <br /> ELL Locatfor �` S Street 6kAmb City ft.e4zlp Parcel# <br /> s J JIfl <br /> tOPERTY Owner Address N n, J� City Zip�,��rv_Phone# <br /> 57 Cpnln3CtQ Address :�Lf"J2 I✓I�I.�. 'l 1 TJLZ Ct Zip Lic# 1 Phona# <br /> insultant/Sub Contractor Addres 1rC S <br /> 108,ty 9A Lic# Phone#C��l� -U <br /> S Coordinates X ula Y_ —f4A _,Township Range Section <br /> 3RK TO BE PERFORMED <br />%(EW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION(choose type below) <br /> ILBO <br /> OI G# Q OVER-BORE <br /> WELL#.. ��.� _ ✓n( [1 PRESSURE GROUT <br /> Cher. Grout Specifications <br />)MMENTS7.0 d t r S <br /> no. IS <br /> P OF tdVELL IN TAL ION TYPE CONf3TRUCT(ON SPECIFICATIONS t it <br /> MONITORING 1-iOLLOW STEM DIA.OF BOREHOLE ULTIPLE CASINGS?11 YES N WELL CASING DIA <br /> EXTRACTION p AIR HAMMERIDREVEN CASING THICKNES . 10 TYPE OF CASING (I5 EL PVC d OTHER <br /> MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 11 AUGERS 11 HOSE <br />�j*GE li PUSH POINT GROUT SEAL PUMPED WYesNo NOTE MAXIMUM FREE-FALL DEPTH IS 3t3') <br /> 301L BORING 11 HAND AUGER GROUT SPECIFICATIONSETHER OTHER APPROX BORING DEPTHCi BOLTlrD TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (PYES ist specifications here) <br /> OMMENTS S t <br /> NOTE: OFFSITE BORINGS EQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> iereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br />)unty Ordinances, Rules and Regulations,and all applicable California State Laws <br /> �f� <br /> I TitlelCompany `I J Sr� �M"�'oe am a <br /> nt Name r Date <br /> DEPARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE,ADDRESS: ce--46,A) <br /> ORK PLAN DATED: Z " Z —b?-- LOQ aX <br /> plication Accepted By Date Issued W 'd Z Area <br /> xA Inspection By pate Flnal Inspection By Date <br /> shmoon inspedlon ey Date <br />:JVNO <br /> DmoN3• <br /> NLY <br /> AID# Terre <br /> E CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT I SERVICE REQUEST# IN <br /> 57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />