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� lS <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> MENj NESN (209) 468-3449 <br /> ORIGINAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> kppllcatior(aYF eby 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 /> NELL Location-'6\'LF <L S . N�\w4 3 3 Cross Street \�\ `TRc � zipo sl-,\- Parcel# <br /> PROPERTY Owner�v.V-�� ' '^ S Address3�'\`\% S.1 Ww A�3 City ` ZIp 1S3 `IPhone# <br /> C57 Contractor�� R Wy21\\: Address <br /> � � \b city`istita, yp°ISl,41uc# `Phone#a1b7-1-14100 <br /> Consul t/Sub Contractor ,LhrP,ddress- 1\b\ -lel` St Cityr(ltio( dO uc# — Pnone#_Z 01 <br /> —_ <br /> GIS Coordinates:X - ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: - <br /> 0 NEW WELL/BORING(GH 1,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# D OVER-BORE <br /> 0PRESSURE GROUT <br /> 'Z, <br /> + � � �WELLi# ,�� W ter- lar. <br /> •Other, yiY� � —Grout Speclficatlons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> It MONITORING j HOLLOW STEM DIA,OF BOREHOLE 2," MULTIPLE CASINGS?BYES ONO W ELL CASING DIA:_____ <br /> 0 EXTRACTION O AIR HAMMERORIVEN CASING THICKNESS TYPE OF CASING: O STEEL J PVC. [)OTHER, <br /> p VAPOR O MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> p OTHER:_D OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> -COMMENTS: \� O"L W") I'lj n <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 wito San Joaquin 1 <br /> County ce ,R Regulations,and all applicable <br /> CaliforniasState Laws. <br /> TtltUqr ���` v [nS l <br /> Signed ` ' <br /> aDate 5 <br /> PrintNm <br /> . lA <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: g / QZ <br /> Applicatlon Accepted By <br /> �(" Sr v Date Issued �ZT/U 3 Area lYS3 <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 Ht iJ �a D 1,g567 C U7� o�j. / a3 i*)/) 3 +3 70 <br /> C-57 ✓ WCJ/-WAIVER_ C-57 etter of Authorization to sign permit ✓ Encroachment docs/ 9/27/00 <br /> CO 39Cd 60013 H13Id EEVE89PGGZ 95:E1 100Z/BZ/Z0 <br />