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"Owl' COPY <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 application is made in compliance with San <br /> ,pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app <br /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,EnvironmentalAssess th Division. <br /> Ci SToCKTo�U ZiP Parcel#-Zn, /0'Or <br /> YELL Location lzJr,Z N StAu/s�Ai�S STAtLT Cross Street Av"_RA City <br /> City (��� .c3f tc++ Zip G o2 Phone# <br /> 'ROPERTYOwnereA41609-6/14 STAFF Address / 6n�Dtys>YoQ� LL Cg33ag2y5 9L53i35360 <br /> l 9� �ocu� City 1`°1_et zip91553 Lic# Phone# <br /> -57 Contractor 6`(41Th ` V_ Address <br /> ,r�jnA.)Lic# Phone#?e9-.? 10S/b' <br /> consultant/Sub Contractor n��"'� �RT� �N.�/t)C.Address/kb� �k � � � Cityy----' <br /> Salm 1 Section <br /> ./ Township Range <br /> SIS Coordinates:X <br /> NORK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> Q NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 OVER-BORE <br /> SOIL BORING# S 621-1019 90- Rsk &125 PRESSURE GROUT <br /> SWELL# 0..,.. � - <br /> Grout Specifications: AlgeAr <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE <br /> OF CIASING� Q ST LYES OQ PVCLL0 OTHER: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS L__ TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> (]VAPOR MUD ROTARY DEPTH OF GROUT SEAL NA <br /> []AIR SPARGE PUSH POINT-C;P I GROUT SEAL PUMPED: 'es No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HAND AUGER GROUT SPECIFICATIONS: A C <br /> SOIL BORING 0 BOLTED TRAFFIC BOX or u STOVE PIPE <br /> - OTHER: OTHERnLccsT Push APPROX.BORING DEPTH /Do FLI f D <br /> CONDUCTOR CASING PROPOSED? AIA (if YES,list specifications here): <br /> Z u o <br /> ,U -o r,2ouAuDcc)A S <br /> 'COMMENTS: S � N ST/G�4 �V <br /> HMENT <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OADVANCEENCROAFOR AL{CREQUIRED INgPECTSIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN <br /> t the work will be done in accordance with San Joaquin <br /> 1 hereby certify that I have prepared this application and tha <br /> County Ordinances Rules and Re ations, and all pplicable Californi ate Lawson tc�y�caoGo�� fiJc, <br /> Title/Company <br /> Signed x � <br /> Date <br /> Print Name DEPARTMENT USE ONLY <br /> 1 � Lap <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1.2052- V� � <br /> WORK PLAN DATED: 2 3 �- (A <br /> 3 <br /> 4_ Date Issued Area <br /> Application Accepted BDate� <br /> Grout Inspection By — <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 501 ;"SS o ,�8 .2 $0 3 C'N�f� 3 zS 03 SM 00-3-3 02 <br /> �_�7 f wr -WAIVER <br /> C-57 Letter of Authorization to sign permit t/ Encroachment clot NA 9�27��C <br />