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i 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 /> kpplication 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 Countyyf2evelopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> , C8 Assessors <br /> NELL Location�L/V -�rYrl� 1 VIS I�£'� `�'t Cross Street is Cily �D)L V ✓] Zip �/ Parcel# Z� 20 I <br /> 'ROPERTY Owner�'�V�111/ ('7r4111 `I10_��__Alp Jddress �nnn ��I� CA <br /> /1 :I j��LI,�� .I. City5 (✓4rQC�1��('L�Lip�"7� Ip Phone# (�f�G'�:7fJ9k� 7�0 � j <br /> -57 Contractor�J,1 C� fl(IPil/ l'iI � 111h✓ Addrelss M, Yr Wyvn IL� 1ro City V �'Zip-19,7"10 Lic#7l OPhoneti I�P <br /> :onsultant / Sub Contractor W/f �' Il� XF�II II M•'I�I�1IAddress Jl.'I 'I 'f�ll �I l�✓li lLb' � Icity •i11 �I � Lic# Phone# <br /> 31S Coordinates: X j V Zqj I - 11 , Y —I ZI �7 :/ZIJ�J�� , Township Range Section <br /> NORK TO BE PERFORMED : - DESTRUCTION (choose type below) <br /> ] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH , HAND-AUGER, OTHER') fl OVER-BORE <br /> H SOIL BORING # <br /> [) <br /> DWELL # PRESSURE GROUT <br /> Other: Grout Specifications: <br /> �.OMMENTS: <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 <br /> MONITORING ` aa HOLLOW STEM DIA. OF BOREHOLE `(j rl MULTIPLE CASINGS? 0 YES X�NO` ' WELL CASING DIA: <br /> ] EXTRACTION 7q AIR HAMMERIDRIVEN CASING THICKNESS? 0 TYPE O CASING: p STEEL R. PVC a OTHER: <br /> ] VAPOR !__MUD ROTARY DEPTH OF GROUT SEAL 311 �11tthEMIE TYPE TO BE USED: p AUGERS p HOSE <br /> ] AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' ) <br /> ] SOIL BORING 0 HAND AUGER GROUT SPECIFICATIO 1 k� <br /> ] OTHER: OTHER APPROX. BORING DEPTH ^ I I ) I hGlb �13OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASIN�G1 PROPOSED`?? f L ( if YES , list specifications hpere)- <br /> -COMMENTS:1Ll_Ol�"i1+0 LkJ ! I U) ll � I2�. 1 ( VI Ujillelf 1.•) IV " ' `i (Yaf -Px'7f.{i Iri � Yn 1X,1� nil�l� - <br /> S, <br /> OTE : 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 /> >igned x � - Z- (/L TitelCompany YY VIeU St� iP,l�l h lS .� 1�� � I'1 YYIUf GVIGI�/ )(1t <br /> 'dnt Name {'11 S Date i0 � WI03 <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS : <br /> NORK PLAN DATED : 6a-sw <br /> Ll <br /> %pplN7 <br /> � _ Date Issued�///3�03 Area 997 <br /> 3rout Inspection <br /> Accepted By Date <br /> 3roul Inspection By �] V - Date I � to D7 Final Inspection By <br /> Destruction Inspection By Dale <br /> :OMMENTS / CONDrrIONS: <br /> ACCOUNTING ONLY: AID# rnru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REI BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> :-57_ WIC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br /> " <br />