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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 San Joaquin County Public Health Services,Environmental Health Division. <br /> P�.b li Works R��9 kt of- 'Cross I <br /> NELL Location(oJ. r,Cj,..")%4I irutr� (Ward Cross Street City S't'be10-0yt Zip Parcel# Q.2 A.1rb,cy�¢s1 <br /> S+a.n lsl•ws,?rK r o ro, <br /> 'ROPERTY Owner Se-e- Address r ity Zip Phone# <br /> -57 Contractor_ 6 p_, oQ of DA.LX� aa�Address <br /> _ City` 7 ILic#G$� PhoBi s� s <br /> -Cenolor \E�wrt� l88 Fr•nk.. W&St <br /> :onsultant/Sub Contractor 'Td,e-�%ho{egj¢S =„G-Address Gi✓. sl�t. I CitY:5+0C +0r% Lic# Phone#r2.09 -O$!8 <br /> 3IS Coordinates:X 'Y Township Range Section <br /> VORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEO_PROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# <br /> 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other: Grout Specifications: <br /> ;OMMENTS: nn / <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z” MULTIPLE CASINGS?0 YES RINO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL p PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY Dl PTH OF GROUT SEAL__& TREMIE TYPE TO BE USED: 0 AUGERS NOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: R"(es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: [OTHER Di rte l&s4 APPROX.BORING DEPTHSu- c►1i'ac. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> :OMMENTS: PHASE Ev.VirOY1W12N�o�l Si-1-� ASSN-SSYvttv�"t': Inydrau<<ic. ollYac-t- D11btS�// <br /> Y 1 v- l l 0.V�� rawr.d wo.-ta r 0.YY� , ENGYDAC� h Qy nsit a►T[YLt✓�0�. <br /> NOTE: OFFSITE ORINGS 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 Regulati ns, and all applicable California State Laws. - I <br /> gned x . Title/Company V%V 1✓'D mswt <br /> int Name bo v;ok h. w a 0� Date '� 18 O Z. <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> 'ORK PLAN DATED: <br /> )plication Accepted 134&� Date Issued 7/ I/� Area <br /> i <br /> out Inspection By Date Final Inspection By Date <br /> �struction Inspection By Date <br /> )MMENTS/CONDrrIONS: <br /> \CCOUNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 57 WC_ _-WAIVER C-57 I etter of Aiithnri7ntinn to Ginn hermit Gn .ay,}=-may+ .e.- n in-7 inn <br />