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•5ECC! u =DWELL PERMIT APPLICATION FORM <br /> SITE <br /> FEB 1 9 Z003SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> MENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> FN4PEnP61T/RO <br /> 1T/�SERVICES C 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> >rr•W..t o.1)cw�ar. 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 /> �.Mt.� Assessor's <br /> L•�Win �iana\ 3) Cross Street aw.n Sjrak City zip 457pZ Assessor's <br /> X3'1-3b-3°I <br /> WELL Location <br /> PROPERTYOwnerSkAumig .lnAddress 001 t�,VN City S10 <br /> 6tt ` ZipQSZDZPhone# <br /> CI ty S ^ K4-TIM $47.98 <br /> Phone#4u$- $o- 1 <br /> C-57Contractor�lol-1C-C-'$- '- AddressI$357nd.z4-G1 nJ" ti Zip CA Licu <br /> su•k7.Ib _ rt <br /> Comitant/Sub ContractorClc Imo+ C�no f ScfA^ Addressb°1ZA tro11 Ulltl Qork..r/City aiem,-4u^(-ic# Phone#qZs 47.b-Z(.Ob <br /> GIS Coordinates:X 3-0 $1 0""r,) ,Y XLl• 1�r�14rVJ Township Range C-C-. Section lb <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) r DESTRUCTION(choose type below) <br /> 0 SOIL BORING# I OVER-BORE <br /> 8 WELL#_ �'(Y1vJ—� obrs.dav�J, O PRESURE GROUT <br /> 'Other: GROUT SPECIFICATION I) rf., <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> *MONITORING I HOLLOW STEM DIA.OF BOREHOLE `1 r� MULTIPLE CASINGS?H YES I NO WELL CASING DIA: Z rr <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL N PVC 0 OTHER: <br /> B VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL — TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes j No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION — <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 29 �t*A- B BOLTED TRAFFIC BOX or I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? '� (if YES,list specifications here): <br /> COMMENTS: 6Ve/ 1u'11 F gn` o..�b ) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ' CALL TTTHNIT IV {7QSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> �( 1. /IC/A- Title/Company_�Z-oltc/ <br /> Signed x�t�t/� <br /> Print Name ((f[14,`1k W161.•AV'tit Date Z.I 10)I03 <br /> SITE MAP IN UNIT IV FILE DDRESS [WORK PLAN DATED <br /> D AR USE ONLY <br /> Application Accepted By Date Issued , Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By ate <br /> COMMENTS/ OND ION : <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT/SERVICE REQUEST If INVOICE <br /> p ZOO 330 zz6 0 3SIR# Z$ �- <br /> C-57_ WC/WAIVER_ C-57 Letter of Authoriza on tosi r it_Encroachment doc_ 7/17/00 <br />