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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., 95202 <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 andlor install the workdescribed. This application is made in compliance vdth San <br /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> c� �A AyC Assessors <br /> ELL Location 3'E ROrN �� _Cross StreetJN1 N c City L+t H��P Zipj573W Parcel# I%63oo.� <br /> M i „ Address•�'� f�� g � City u' 1 �Zip_ 5�3 Phone#�° � 9ice' <br /> ZOPERTYOwner. nA]►�1Z1 FET1( _ <br /> S7 Contractor�Ct✓Ci�ifVl �(r)��i _Address 1+�t�0 S. �n ��' VC,,ity�tcwcfl(+ Zip Lic#��S�hon 510 °237- ��7 <br /> onsuttant/Sub Contractor�x��l=.n (1 �k; Address Jh1'7 VON Ni1Jti1Qn City 1 YI N� Lic# Phone ��- IDf C <br /> IS Coordinates:X ,Y ,Township Range Section <br /> IORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT G OBE HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION(choose type below) <br /> SOIL BORING# 1 �f�� F 45Q OVER-BORE <br /> ❑PRESSURE GROUT <br /> � <br /> Ither: WELL# Grout Specifications: <br /> :OMMENTS: ICTAL GF C 'c fC ' enc rC' <br /> lC�7I� k:l - CIDLct • <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Le.IY�2t� <br /> MONITORING I]HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES Q NO WELL CASING DIA: <br /> ]EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ()STEEL 0 PVC []OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 1]HOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: []Yes 1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> ]OTHER: OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or inances, Rules and Regulations, and all applicable California State Laws. <br /> _ ctnd I�recls++� S�mp►irx� <br /> Signed x E 'T MOf�11EIZ� EL_ "Lf- �-C Title/Company Gli <br /> Date 0 <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: <br /> WORK PLAN DATED: 3 3a <br /> Date Issued S 2—, <br /> Area <br /> Application Accepted By <br /> Grout Inspection By Date Final Inspection By n t 9'�/u� Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDrfIONS: LA.�e— <br /> I <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ <br /> C-57 Letter of Authorizati n to sign p rmit_Encroachment doc 9/27/00 <br />