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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 /> .pplication 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 /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Bloc-k 2t b0--j-"LV/ L7r0'K j Assessor's I <br /> /ELL Location MiP.e.r, /�Kror..�+C1A,'%r.a.I Cross Street City S�oe1C.}'py� Zip `152.OL Parcel# 3QA o.�',"g. k Lj <br /> 'ROPERTYOwner Se-e- 06*064-IgQA Address City Zip Phone# <br /> -57Contractor Viv'O .NQ.YG T-Y►G-. Address 2.110 AdI0.m5 Aves .r, 405 <br /> • Cityl.�a�►„�ro Zip9'{S ic# 905 Phone#510-$0-J(e� <br /> Cen or wr�(ti !$8 �r•n(� VjLSt <br /> onsultant/Sub Contractor_'Te-c-�%P%olOWiet, =►+-.•Address Ci✓. . S-tc. I City�tockfOr� Lic# Phone#,Z.O'I-23.1-05!8 <br /> 9-0 -1 <br /> IS Coordinates:X 'Y Township Range Section <br /> !ORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> )ther: Grout Specifications: <br /> OMMENTS: <br /> (PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS? DYES ff/NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: 0 AUGERS WI-IOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 6es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ``�' <br /> OTHER: [�OTHERDirL& PIAs4 APPROX.BORING DEPTHS" aw.46me- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r}- CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> OMMENTS: PInasa !L Ey�VryoylYYl�v�I ail Si-h� ASSe-SSvntvti"t" �yotr_ ou<<i a(IYa_c{ Dt�S� <br /> ri r i l a.v�of ra�►�d <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 /> iereby certify that I have prepared this app ication and that the work will be done in accordance with San Joaquin <br /> aunty Ordinances, Rules and Regulations and all applicable California State Laws. I <br /> 3ned x _I Title/Company Env e_v-V. (_O yLAOX^ <br /> nt Name DO-V 1 0( K W O Od Date <br /> ZD 7— <br /> DEPARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE, ADDRESS: <br /> ORK PLAN DATED: // '/ <br /> plication Accepted By L�,tfo-�( Date Issued V/W62- Area <br /> out Inspection By Date Final Inspection By Date <br /> struction Inspection By Date <br /> )MMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 06ag60 i --j <br /> 57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />