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GLI CJLr LVr l <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 is made in compliance with San <br /> >ppiication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application <br /> Joaquin County Development Title,Chapter 9-1115.3 and.the Standards of San Joaquin County Public Health Services,Environmenta <br /> Assessor's <br /> l Health Division. <br /> �p Cross Street L6-t. • City '"1�(" ccs Zip Parcel# <br /> W L Location `w <br /> City Zlp Phone# , <br /> PROPERTY Owner �i l'}rc. 15 Address 98od 63�3gJ (ter/a 137-g37 <br /> Address �f ua S. St. CityZ_�°^! Zip -�Ic# Phone# <br /> C 'Contractor <br /> e# <br /> Consultant I Sub Contractor <br /> ?- ��,� Address <br /> Coordinate sj.> �'S7`17, 8*5 J 1 c,0 gay Township <br /> Range Section <br /> L--a gY'cllo PaLc(n f <br /> IRK TO BE PERFORMED, [)DESTRUCTION(choose type below) <br /> `*NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) []OVER-BORE <br /> [)SOIL BORING# PRESSURE GROUT <br /> [) <br /> WELL# <br /> Grout Specifications' <br /> --her. ASO v I�1 ° 10, ?1'PL 1 --� I-I r e <br /> COMMENTS: a 4 - <br /> �E OFWELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING n HOLLOW STEM DIA.OF BOREHOLE!Z�( MULE CASINGS? <br /> [)STEEL O[) WELPVC L[]OTHER �. <br /> n EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS <br /> IAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> -2o Ft TREMIE TYPE TO BE USED: [)AUGERS d HOSE <br /> ,,.fAPOR- GE `a MUD POINT GROUTSEALPUMPED: [)Yes �lo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [)HAND AUGER GROUT SPECIFICATIONS: <br /> )THER: U OTHER <br /> APPROX.BORING DEPTH .2D X,t+-- 0 BOLTED TRAFFIC BOX or 1)STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specification®here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESSVOANCErFCROACHMENT PERMITS. <br /> OR ALL EOUIRED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN At <br /> 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 /> Tiidelcompany <br /> igned x <br /> Date <br /> rint me DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued <br /> Areas-- <br /> kpplication Accepted By Final Inspection By Date----- <br /> Grout Inspection By Date <br /> Date <br /> )estruction Inspection By <br /> ;OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> „� ,inn <br />