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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 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplication 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 /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 1� r' Assessor's <br /> VELL Locatlong5D6 5, Hari f 61 Cross Streetw k!,City r(c:(YI'1 111 ZipCi5.�3'i Parcel# //L ,5 <br /> 3ROPERTY Owner MGN I F P`�t F-E N I LIE . L.L� Address 95C S: Hcy r�n 1 City Fr-Cl .h I 0 Zip I _�1 Phone# 2N <br /> -57 Contractorff�[ .t�iC l ��m�lt�_Address tLII�O 5, JV" J�r��� City 1 )O)C.ck Zip Lic#L�663 Phone# 7�J -9 ' �24` � <br /> ;onsuttant/Sub Contractorbrug—) Cil CSU I 1 Address IC135 �C'(1 f(YIC.I(� City (N& Lic# Phone �l ��C C <br /> 31S Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED: <br /> ]NEW WELL/BORING(CPT EOPROBE HYDROPUNCH,HAN�-AUGER,OTHER') Q DESTRUCTION(choose type below) <br /> SOIL BORING# 1 mAL- SDE OVER-BORE <br /> [I WELL# ❑PRESSURE GROUT <br /> `Other: Grout Specifications: <br /> COMMENTS:�GTAL t1F `� �F� rL'��' IDC�rtlYth tC Gl (i X • a0--30' bn5 ('lfl(1 �Cllt CT (1((lt :iL <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING [I HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[I YES []NO WELL CASING DIA: <br /> Q EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL p PVC []OTHER: <br /> VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 1]AUGERS 1]HOSE <br /> AIR SPARGE ❑PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> Q <br /> OTHER:_U OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> - <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed �a� b4GNT FCK Ix WtE �1fi .�llT L1 - Title/Company 1Jt CtLN ZL�JI�� �1 <br /> Print Name �(tL�l/ �71 t17 Date I T I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:— <br /> WORK <br /> DD ESS:WORK PLAN DATED: 3 3e [ / <br /> Application Accepted By Date Issued E Area/ <br /> Grout Inspection By Date Final Inspection By i"Z� t�� Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: ;AID#PE CODES FEE INFO REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br />