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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT 1V <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> plication 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 /> iquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Sib 2 ` / (,V / ,0 Assessors <br /> .LL Location ^^,,G,� /r/ay'rC��+ I��Cross Street k •Crity �''eKck 4�ip S Z I Parcel# /I 9 3 Z I G[�3 <br /> :OPERTY Owner &it fir.L,�e t•r[e L•LeAddress KD Fr 5 /A✓lir" ju Ci y�-4 ��h� Zip �C S'ZS hone#(-Zc"?) (173 <br /> G,�� �<l Address.77 aZ li W 4 -f !/ ty St tip^ ?�f( ���# �gS�PF�ne# �2� �2 6M <br /> 57 Contractor H�.. lIK_ Ci <br /> /n� cf+k <br /> nsultant/Sub Contractor u S C dY� <br /> Address s� � S*J"r�� -ty � i # Phone �� <br /> 5 Coordinates:X Y Township Range Section <br /> ARK TO BE PE ED: <br /> VEW WELr OR G ICPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> VOIL BORING# OVER-BORE <br /> 0 WELL# ©— 0 PRESSURE GROUT <br /> ther: Grout Specifications: <br /> :)MMENTS: <br /> 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE 2 MULTIPLE CASINGS? YES �NO WELL CASING DIA: <br /> EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE USH POINT GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL EPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: 0 OTHER APPROX.BORING DEPTH /O BOLTk TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? dV (if YES,list specifications here): <br /> :OMMENTS: <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, and all applicable California` State Laws. ' <br /> gned x 4// ,(n —�/ Title/Company ✓r P1�X� NIQ�q'��✓ uX S <br /> fnt Name G- / K��c( LU I /a k Date I 2 U Z <br /> DEPARTMENT USE ONLY <br /> J r- <br /> ITE MAP IN UNIT IV FILE, ADDRESS: S� S' �''rI Q r� t-re" �� C <br /> IORK PLAN DATED: <br /> )plication Accepted By Date Issued r� Area q <br /> rout Inspection 8y Date Final Inspection By / L Date V <br /> estruction Inspection By Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# J <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> :-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/„?7/00 <br />