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{ <br /> WEL ERMIT APPLICATION 1JkM <br /> SIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-; MITIGATION <br /> ILE C P ' ENVIRONMENTAL HEALTH DIVISION (PHS-"D) UNIT�V <br /> 304 E. Weber, Third Floor, Stockton, CA., X5242 <br /> (209) 468-3449. <br /> 3b , i <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 /> WELL Location �� 11 At+�[-(L 1{1 Cross Street �0` n O City cYCt)�n zip }SZbZPAssessor's <br /> AssoAZ—( 3 Z3 <br /> �ySk2rn �; PSA gni I�3� <br /> PROPERTY Owner s ,;, fi�v Cc, ¢� �pddress 6M1 qp��y {2_��-.` City5 -\ PL 2ip�S�Phane#�T z5 <br /> C-57 Contractor �� 1��5 Address 3C i ,, �'N\e- City R _ziAS'74Z Lic#-7{]&I0 Phone#q l —lo <br /> Consultant/Sub Contractor WAddress Ki I City�tts tNcJ., Lic# il, Phone# <br /> i—vii V <br /> GIS Coordinates:X Y Township Range Section <br /> w K TO BE PERFORMED: i <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BORING# Q OVER-BORE <br /> GVELL# 3 Q PRESSURE GROUT <br /> 'Other: !/ � Grant Specifications: ' <br /> COMMENTS: <br /> T—YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ` j <br /> ONITORING OLLOW STEM DIA-OF BOREHOLE .gr, MULTIPLE CASINGS?d YES �NO WELL CASING OIA: Z <br /> D XTRACTION A R HAMMER/DRIVEN CASING THICKNESS 11 rTYPE OF CASING: [I STEEL PVC 0 OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL , TREMIE TYPE TO BE USED: UGERS p HOSE <br /> FAIR SPARGE 11 PUSH POINT GROUT SEAL PUMPED: es 1]No (NOTE: MAXIMUM FREE-FAL DEPTH IS 301) <br /> {]SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS: A C��1�� <br /> © <br /> OTHER: []OTHER APPROX.BORING DEPTI I %3(OLTED TRAFFIC BOX or ;U STOVE PIPECONDUCTOR CASING PROPOSED? ,list specifications here) <br /> ,COMMENTS; E <br /> 7. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. k <br /> I hereby certify that 1 have prepared this application and that the work will be doge in accordance with San Joaquin <br /> County Or - —Rules and Regulations,and all applicable California State Laws. <br /> Signed xTMe/Company Y T 1 C r. }` <br /> Print NameDate- <br /> DEPARTMENT <br /> ) �f3 <br /> Q{t;a,5 Si�v{� Date `��i�101 t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: :3Z3:5 S- <br /> 1 <br /> WORK PLAN DATED: I: <br /> Application Accepted By , Date Issued l�/�!� 'Area " <br /> Grout Inspection By Date �� d Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONbfr10N5: <br /> i <br /> FACCCIN INTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECS BY DATE PERMrrI SERVICE REQUEST INVOICE <br /> f <br /> Z o� 4� � dGz <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc ' 9/27/00 <br /> t . <br /> E8 3�d �i001d tildId -. . EEbE89b60Z TE:ET ?0013Z/VO/ZZ i <br />