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j� WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> MP MENS NE ESQ (209) 468-3449 ORIGINAL <br /> E`vVICj�RV�G NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> violicatioro 1\by 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 Mile,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> rr Assessor's <br /> (YELL Location\.'A` RS • �\\w� 3 . Cross Streat ��^r\}\`a..,'Cy-mGlty,T1 i2ip�gS 31\. Parcel# <br /> PROPERTY Owner�v.A.�2.� �p_r�S Address3�Ak% S.1\w, 3 CityIZip`S3)� Phone# <br /> D57 Contractors a�1 v�.=�\:� Address e1� �3 `��b Cay 2s4.t�tv�vpl-< L"# Phone#� <br /> �— f,f;C.1 ��b� ��� Sfi Ci I I IC)�JIO Lic# Phone#-Z-0 <br /> Consul t/Sub Contractor C���L-�I Address tY <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0 NEW WELL f BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) OVER-BORE <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> SSi9_ �WELL4—_ �_ <br /> *Other. � 1 '_-- W�c' la,-. GroutSpeclfieatlons: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING j HOLLOW STEM DIA.OF BOREHOLE ZN' MULTIPLE CASINGS?BYES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION p AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL J PVC. 0 OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS p 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 0 HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH r <br /> p CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> 'COMMENTS: W'3 -)C'b01 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4B 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 <br /> ,A <br /> County ce ,R Regulations,and all applicable California State Laws. <br /> Signedx Tide/Company <br /> Print Name \` :!j y-o\A- Date 5 - S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: e /Y .Z <br /> // .v Date Issued 061ZT�1)3 _Area 1'15'3 <br /> Application Accepted By /Vv-( '*�% "S <br /> Grout Inspection By <br /> Date Final Inspection BY Date <br /> Desuudon Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID#, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> 35o 1 )44 IJ $ g9 01'q-56,7 <br /> y567 CkT? oy- os C. 3)+3 70 <br /> C-57 ✓ WCJC WAIVER_ C-57 etter of Authorization to sign permit 'Z Encroachment doc,_1[_ <br /> 9/27/00 <br /> E0 39dd H007A H1dId EE4E99b60Z 9G:ET T00Z/9Z/Z0 <br />