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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 ORIGINAL <br /> NON-REFUNDABLE 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 of San Joaquin County Public Health Services,Environmental Health Division. <br /> NELL Location\\Q 0,3 W ' y urtw n T urM Cross Street CI Try c- �S 37b 'lessor's <br /> T ry y_Zip Parcel# D.S 6' - I o D y <br /> G;QI'.wl f Mie V�C�+A}.r� � a <br /> PROPERTY Owner ! ` 4L(-o,nv St+'. Address kb0 ZA CityI C__q _.. Zip9S 1Phone# 035 - 33"7q <br /> oll,o <br /> C57 Contractor V �t W 1(L:\\:Addresrs�yXJ �\\a City Zrp t. _ Uck_ Phone#`\\) 'l-11 y l'0 0 <br /> I e.cL.�:cS -1}h <br /> Consul t/Sub Contractor Gk A o�,Q9 Address_ 11y 1 S-T. City 1 r '000,''0 jic# — Phone# 2 U 9 S 2,-- y A 9 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION(choose type below) <br /> D SOIL BORING# D OVER-BORE <br /> WELL# t%%W O1 til t O 6 i Zo t D PRESSURE GROUT <br /> *Other. SA-lt. o k o.t,ha .1. 4 1Y1oZ wyrY.4\m. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING $HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?DYES ONO WELL CASING DIA:_ <br /> a EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC. D OTHER* <br /> — <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS D HOSE <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER;_G OTHER APPROX BORING DEPTH D BOLTED TRAFFIC BOX or O STOVE PIPE <br /> (� CONDU TOR CASING PROPOSED? (If YES,list specifications here): <br /> `COMMENTS: 0.� tCo`U $ <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordrtes, le eicable California State Laws. J <br /> Signed x � gulations,and all appl/ Title/Company <br /> Print Name �n��d. ``Ala n Ow Date ��3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: //4DD Dorlw� F-eyi y ?cA <br /> WORK PLAN DATED: A-oQstt i4-2cog- <br /> Application Accepted By GCc�( C,7S/cL�G �G� Date Issued /UT3 Area <br /> Grout Inspection By 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 I SERVICE REQUEST# INVOICE <br /> 3501 1 MW L031 sg# 003434 <br /> C-57_A/, WC ✓-WAIVER_ C-57 Letter of Authorization to sign permits Encroachment dock 9/27/00 <br /> ck&k 4: $ 179 c r 2 per—+y <br /> CO 39VJ 600'13 1-113I3 EEbE89b60Z 99:E1 T00L/8Z/Z0 <br />