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I <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <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 /> %pplication is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Developme Title Cha r 8- 111,5 and ee Standards of San Joaquin County Public Health Services, Environmental Health Division . <br /> 41 <br /> Assessor's <br /> NELL Location. I I �I NI7 ross Street City 1 .v k ✓( Zip Parcel# <br /> ( 44 W%'c 4'L L'1111 v1 w'Qics (5a i <br /> I CityZip Phone#°ROPERTY Owner - Address <br /> L <br /> -57 Contractor - . IJV - Vt Address '�1 �7� INV11 [I/ l '.Ir City (^ i(Kayo <br /> ip1J� �" Lic# I�(] Phone# �1)onsultant / Sub Contractor J I �i' � d Address i " � Lic# Phone# MI (11� �3(1 l - ©'-� Cl� <br /> cxj 000 (,i� asc� �o <br /> 31S Coordinates: X., Y., Township Range Section <br /> ORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') OVER-BORE <br /> H SOIL BORING # GPRESSURE GROUT <br /> ^rl'GJELL # StiU-I IY)/ I 4� ` � � Vt( ISJ ' <br /> 'Other: ff Grout Specifications: <br /> :OMMENTS: <br /> rY E OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ' / 11 <br /> MONITORING H HOLLOW STEM DIA. OF BOREHOLE_ MULTIPLE CASINGS? H YES NO WELL CASING DIA: 9 <br /> ] EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS t ' I , L TYPE QF CASING: .H STEEL PVC H OTHER: <br /> ] VAPOR H MUD ROTARY DEPTH OF GROUT SEAL � I Irj� 7 1, REMIE TYPE TO BE USED: GAUGERS H HOSE <br /> ] AIR SPARGE H PUSH POINT GROUT SEAL PUMPED: fVyes H No (NOTE : MAXIMUM FREE-FALL DEPTH IS 307) <br /> ] SOIL BORING H HAND AUGER GROUT SPECIFICATIONS: �Zl <br /> ] <br /> OTHER:.H OTHER APPROX. BORING DEPTF+V^_aa ' s OLTED TRAFFIC BOX or H STOVE PIPE <br /> /� �� � I I t�, ,^, COND,LU,CTOtR�CIASINaG PROPS D? 1 f) ( if YES, list specificationns� here): � > �\ <br /> COMMENTS:,W(° II MI,U i filylk /l �I/1II b? ( t� I& <br /> \i L(IA�A WItk Ill �� all -_ IIVt <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 /> jounty Ordinances, Rules <br /> and Regulations, and all applicable California State Laws . l f p O <br /> Signed x t/r v r- <br /> M� i,( Title/Company 1 / LL � I <br /> - <br /> _ Date <br /> 'dntName l DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS : <br /> NORK PLAN DATED : / <br /> %pplication Accepted B ` M-p u Date Issued��/ 3�bT Area <br /> 3rout Inspection By Date [_ D d Final Inspection By Date <br /> )estruclion Inspection By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# carve <br /> PECODES FEEINFO AMOUNTREMrTTED CHECK # RECD BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 3 Sbl � � r � <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/ 27/00 <br />