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- <br /> � � <br /> u C-1 <br /> FD-)' ELL PERMIT APPLICATION FORM SITE <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT <br /> IV <br /> {" ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT V <br /> cl- 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> `'-- � (209) 468-3449 �B�' CO� <br /> �- Cl) <br /> C:) <br /> u� NON-REFUN❑ABLE PERMIT EXPIRES I 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 a an Joaquin County Public Health Services Environmental Health Division <br /> P� � Assessors/n�,�,,,, <br /> WELL Location `/'� Cross Scree � � City Zip Parcel# L..L'l�i Raw <br /> PROPERTYOwner C( - T0c rn Pdress.7.SOC� /�A✓y��CIty. s-'Z ck� Zip 2p Phone# 1J/` �b <br /> /�J� 6AIV) - _ -diesm-3 .` City -Iles r Zip g5�_Lic# 6�SPhone# !TZ' 35�� <br /> C-57 Contracto�y_ . . ,. r /- <br /> Consultant!Sub Contractor G Y� a T Address }Q�� 1—/c.t� �✓ �ty Lic# Phone# <br /> I ' GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> 0 NEW WELL!BORING(CPT GEOPROBE YDROPUNCH HAND-AUGER OTHER-) 0 DESTRUCTION(choose type below) <br /> ' j] ING# 0 OVER-BORE <br /> []WELL# a PRESSURE GROUT <br /> 'Other Grout Specifications <br /> ' COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASINGS 0 YES []NO WELL CASING DlA <br /> WXTRACTION []AIR HAMMERJORIVEN CASINGTHICKNESS TYPE OF CASING 0 STEEL 0 PVC 0 OTHER <br /> APOR 0 MUD DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ©AUGERS OSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED a Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS w``6p�7y-_ <br /> {-OTH RE RE ww 0 OTHER APPROX BORING DEPTH IlK [}BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_(if YES lost specifications here) <br /> ' 'COMMENTS <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 /> ' <br /> I hereby certify that 1 have prepared pp re ared this a llcatlon and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, andall applicable California State Laws <br /> Signed r Q i set,r Title/Company 6DA/2) <br /> Print Name oAL X Date <br /> ' DEPARTMENT US,/E,OdNLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS ayeli� <br /> ' WORK PLAN DATED to-3 <br /> Application Accepted By Date Issued rl Area <br /> ' Grout Inspection By Date Final Inspection By Date_ <br /> estructLon Inspection By Date <br /> MMENTS!CONDITIONS <br /> ' ACCOUNTING ONLY AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> ' 'M - ice �JSZ <br /> r-q7 1Alr ./-V1AT1/PD ("-97 1 otter of Authorization to Sion Dermit Encroachment d-1 9/27/ 4 <br />