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0AY 14 Zoo�LE COPY <br /> WELL PERMIT APPLICATION FOM -BETE <br /> -BVI ITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 -IIP <br /> (209) 468-3449 A <br /> `F <br /> IV. <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> :iplicafion is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> :aqu in County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> � ily�n^r-Me Ce�JZip"L`J4dLldl��� <br /> Assessor's <br /> 'ELL.Location Cross Street R5� :ity Y1YQZipj3��P Parcel# <br /> tr � <br /> ROPERTYOwn ` �yk Address � City�Zp Phone# <br /> :-ST Contractor� C,�LAddress�.2 5-1 FgAj,�LC1 <br /> � s-7a7(a <br /> T� \ 1 1 cµee4 /' <br /> ;omwitant I Sub Conhacbr UV'6w�a I�-we 1� Address '�1 •Ci V l G Uy City wrcl--k Lic# Phone#l2 )`j s 9G 11 <br /> 7- <br /> its Coordinates:X ,Y ,Township Range S� Section 3 <br /> VORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> I NEW W ELL/BORING(CPT.GEOPROBE.HV PHM' AND-AUGER,OTHER') 0 OVERBORE <br /> 0 SOIL BO # <br /> 0 <br /> N W ELL# — t I PRESSURE GROUT <br /> Other. Grout Specifications: <br /> COMMENTS: <br /> E OF WELL TALLATION TYPE CONSTRUCTION SPECIFIC TIONS <br /> j ONITORING ■ To <br /> STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS 1 D(0. . TYPE OF CASING: OSTEEL PVC OOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: C CACr.t� C <br /> 0 OTHER: 0 OTHER APPROX BORING DEPTH So 0 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 /> 1 hereby certify that 1 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_ pp <br /> Signedx Tille/Company_ C- &- <br /> --0\2�I1" - awh aW-( eatc[45 <br /> Print Name PS�cX e� C� Date<- <br /> DEPARTMENT/VAS ONY <br /> L <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 75 /t/ - ' � 1 �a <br /> // 01 <br /> WORK PLAN DATED:_Z CT vim' 'UI <br /> DkO <br /> Application Accepted By Date Issued r / Area <br /> Grout Inspection By Date Final inspection By Date <br /> Destruction Inspection By Date <br /> s <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z o w 5-rSR# 'Up <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/C <br />