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� - - FILE My <br /> Y<' <br /> APPLICATION FORM <br /> � WELL PERMIT SITE . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> � ` <br /> C`p ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 0 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,pplicaGan 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 County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division., <br /> Assessor's <br /> YELL Location Cross Streeter f�City Sr`��K� s slip Parcel# f5'�'ab� /O <br /> "ROP ERTY Owner dt'vck< l a City "SY`acK Zp Cz-7Phone#_x'29-I;7a, <br /> :-57 Contractor if iSc.�7 L-n adt/ <br /> dress 5 yr�-i s �lR Clay dl( P Y�J`LLic#683 phone# <br /> !&g"fir::-rv,LfI�rFC%,cL<c <br /> :onsultantlSub Contractor ( Address S CityLq-j-r •. Lic# Phone# <br /> t 209-2�y-dr'ig <br /> AS Coordinates:X Y Township Range Section <br /> •YORK TO BE PERFORMED: <br /> ]NEW WELL 1 BORING(CPT,GEOPROSE,HYDROPL NCH.HAND-AUGER.OTHER-) a DESTRUCTION(choose type below) <br /> $OIL BORING# OVER-BORE " <br /> I7 WELL# PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> "OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NO WELL CASING DIA: <br /> j MONITORING Q HOLLOW STEM DIA.OF BOREHOLE: 2 �� MULTIPLE CASINGS?[I YES g <br /> 9 EXTRAC TION Q AIR HAMMERID RIVEN —'CASINd THICKNESS TYPE OF CASING: I]STEEL ©PVC [I OTHER: . - <br /> g VAPOR MUD ROTARY , P DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> j AIR SPARGE #PUSH POINT (7` GROUT SEAL PUMPED: Q Yes ®'No (NOTE: MAXIMUM FREE-FALL DEPTH 1S,301 <br /> OIL BORING []HAND AUGER GROUT SPECIFICATIONS: lVe-gt- C-G✓ham <br /> I OTHER: BOTHER Y�,r�c r P-rJ APPROX BORING DEPTH ��� Q BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? P)l� (if YES,list specifications here): <br /> 'COMMENTS: i5 So' �o,rr fb S✓ J. 1� :Y J "Ca/�Gc.T Z �;� d � <br /> NOTE: O FSITE 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 wiI! be done in accordance with San Joaquin <br /> County Orth nces� Rules <br /> and Regulations,and all applicable California State Laws. <br /> Signed x 71t1e/Company l <br /> 51-�c.-r+T (� i� ( <br /> - ems <br /> Print Name . "--LDEPARTMENT USE ONLY ; <br /> SITE MAP IN UNIT IV FILE,ADDRESS: , <br /> WORK PLAN DATED: /� <br /> r Area `�6 <br /> Date Issued'" ���� ��' <br /> Application Accepted By Date <br /> Grout Inspection By bate '... Final inspection <br /> Destruction Inspection By Date <br /> COMMENTS!CONDMONS: <br /> ACCOUNWW -WAIVER—i-57 <br /> D# lr ! <br /> HECK# RECTO BY DATE PERMIT 1 SERVICE REQUEST# INVOICE ! <br /> PE CODEMOUNTC - <br /> Sii:a <br /> 0030 b� <br /> C-57 etter of'Atrthorizafiion to sign perrl►itT� Encraac� h oc <br /> • 9/27/00 <br />