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WELL —ERMIT APPLICATION FOi <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Thirdfloor, Stockton; CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> 3ppllcation 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 Sari Joaquin County Public Health Services,Environmental Health Divlsion. <br /> ��� �N • ` UScr..+ t S•u r1i�� °k5 3 3 Assessor's <br /> HELL Location „Cross Street City MCI'11 r-C-, Z€p Parcel# d t°1 0 <br /> Geo,r�.w, .c, <br /> PROPERTY Owner o K oti},S-s Y.K Address S 0 u City.Tcx,. 0. Zip Phone# <br /> �1 (LA �+1 Address P b Q �y 11,, <br /> C-67 Contractor � C€ty 4h Zip S�l Lic)# Phone# <br /> / �,�;c S <br /> �ansutta t/Sub Contractor G e o\o�; Q, 1 e c Address 1:14 M I A IJ&& ( City11 100(U ro Lic# — Phone# S a g +o a y <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> NEW WELL f BORING(CP GE�3f'Sfl6 HYDROPUNCH,HAND-AUGER,OTHERS ©DESTRUCTION(ch type below) <br /> 11 SOIL BORING# L} OV -BORE <br /> a WELL# P ES E GROUT <br /> 'Other; Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING j]HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> a EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS 'TYPE OF CASING: []STEEL a PVC. U OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS j]HOSE <br /> a AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: " <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX or []STOVEPIPE <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 nces, les nd TILlations, and al[applicable California StateLaws.Signed x — 'w TftlelCompany CTiy�U G <br /> Print Name { 0.� et(l;1 Le,v,-) Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: `1 2is <br /> Application Accepted By ! I Date Issued a I Area <br /> Grout Inspection Ely.......................���DateFinal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: " <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* IRECIED BY DATE PERMIT/SERVICE REQUEST# IQC <br /> C-57 WCC WAIVERC-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> CO 39Vd 600-13 HIJI.d EEbE89b60Z 95:£1 T00Z/8Z/Z0 <br />