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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., 95.202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> )plication 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 /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> �1 7—�� r '5'A4i K I fj r Assessor's <br /> ELL Location ;, &71,, �.�ck Cross Street �I -�7� � ( City � I �tnbo� Zi Sq 3 t� Parcel# (g�(23C112 'Z <br /> ROPERTYOwner <br /> /1�"IMl�/21�`///'le L�'� Address34a ISO18//4 � Cit /'`t/�rD p' Zi' S3SOPhone#��o1J/� �7 <br /> .57 Contractor G )aed[ Address a 7a4 �'t 14J 1."e Ciity'l'/Na.,ellIlip`OO��iC* l�yPhone4512-)i-- ?-7-i al <br /> Dnsultant/Sub Contractor �/°C S Address ULD L 07_5/ �itecl te'�01_Lic# Phon <br /> 7/0,-3 <br /> IS Coordinates:X 'Y Township Range Section <br /> ORK TO BE P D: <br /> 'NEW WEL BORING( PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> >rSOIL BORING# U OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> )ther: Grout Specifications: ' <br /> OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM DIA.OF BOREHOLE. -(nfr MULTIPLE CASINGS?a YES ANO WELL CASING DIA: <br /> EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: []STEEL Q PVC 11 OTHER: <br /> VAPOR H MUD ROTARY DE PTH OF GROUT SEAL — TREMIE TYPE TO BE USED: a AUGERS Il HOSE <br /> AIR SPARGE )rPUSH POINT GROUT SEAL PUMPED: 0 Yes p No NOT : MAXIM M FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: /0-OTHER APPROX.BORING DEPTH n BOLTED TAAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? h0 (if YES,list specifications here): <br /> 'OMMENTS: <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 /> :ounty Ordinances, Rules and Regulations, and all applicable California State Laws. `�� �J <br /> igned x f���/yy/ �r/f��' Title/Company51 PrDD°Gf�GlI�'{7v / /� <br /> rint Name Z-1." , 011�I Li_k Date <br /> DEPARTMENT USE ONLY <br /> ;ITE MAP IN UNIT IV FILE, ADDRESS:- 3 q 2 l <br /> VORK PLAN DATED: LvY <br /> ,pplication Accepted By I Date Issued l(J U Area <br /> ;rout Inspection By Date Y Final Inspection By Date—'�T 2. <br /> lestruction Inspection By U Date <br /> :OMMENTS/CONDITIONS: 22U <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICER UEST# INVOICE <br /> p a 6� 4 �6-') V"- — - I � �' � <br /> -57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9,27/00 <br />