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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 /> Daquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> 1310Lk3' b0 <br /> Nn6(&O"7 Akro rqJ <br /> !ELL Location M;Ks-r, 0 PAA. i C.Iia K ,l Cross Street Assessor's <br /> Ci ty �COyt Zip Parcel# Q2 o +oe_L, j <br /> 20PERTY Owner 5 Gt- cx*P" G.IN" Address <br /> / Sor+itY/ Zip Phone# <br /> -57 Contractor ViroymyC I.Y1C.. Address21I0 Aa(a,ti� Ave,. Ci L.aw�d 405 <br /> ty ro Zip9`{$ ic# 9L� Phone#510-$(rg-4(e� <br /> Cen or ar'1k 188 Fir-•nk. Wttt <br /> onsultant/Sub Contractor_'TiLe.kKOlealieS =nG-Address_Cir. , Ste—- Z CityociC{Or1 Lic# Phone#.209-Z3-1-O$18 <br /> S Coordinates:X Y Township Range 9 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# <br /> 0 WELL# 0 OVER-BORE <br /> 0PRESSURE GROUT <br /> ther: Grout Specifications: <br /> :)MMEN 16: <br /> PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z" MULTIPLE CASINGS?0 YES ff/NO WELL CASING DIA: <br /> #TRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> /APOR 0 MUD ROTARY DEPTH OF GROUT SEAL Joh TREMIE TYPE TO BE USED: 0 AUGERS V-IOSE <br /> \IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ffl<les 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 30IL BORING 0 HAND AUGER GROUT SPECIFICATIONS: `t'' <br /> ETHER: [OTHER Dl r!tt FAAsh APPROX.BORING DEPTH�5" '%4'mc. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �}. CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> :)MMENTS: Pko.Slz 11 E1nViy'oYtYV12N}al Si-1-e. ASStSsw«vt"t" �ydrwK�ie. a(jYyc-E- DNS1� <br /> ri l 0.Kd ►�DwV�d w0.-t-Q.w a w. 1 <br /> NOTE: OFFSITE EYORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> unty Ordinances, Rules and Regulation , nd all applicable California State Laws. <br /> nedx I 1, II Title/Company EhV. e-YV, t^. 0yLd.0-Y" <br /> it Name 0.VlR K. WDr7dt Date OZ <br /> DEPARTMENT USE ONLY <br /> 'E MAP IN UNIT IV FILE, ADDRESS: <br /> )RK PLAN DATED: p <br /> lication Accepted By .� C� Date Issued y/a�//OZ AreaAV�) r OS <br /> it Inspection By Date Final Inspection By Date <br /> :ruction Inspection By Date <br /> AMENTS/CONDITIONS: <br /> :COUNTING ONLY: AID# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 70/ F3(161 ,Ue ani v <br /> 7 WC -WAIVER C-57 Letter of Authorization to sign permit Fnnrnnnhmpnt rInr 9/97/nn <br />