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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,C4haJpt-err 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> I31ork'4 ' 1po-t-= b St0.KltiIpN1� Assessor's 1� j <br /> YELL Location Ct1aK�l� Gnus- 0 + WiL6ALv- Cross Street City sto-1---0yt Zip Parcel#_ QR A.7j'a.��4✓t <br /> 'ROPERTYOwner 54Ll. 0. AC�►�� Address City Zip Phone# <br /> :-57 Contractor YtYONQ-YG 7--Y1f Address 2.110 Aa0.+14S AVe.• 4057 <br /> CitY_4w rc Zip1197-Aic# c 4 Phone#5/0-$(8-4(o -40 <br /> Con or a►-�k 188 Fp-..Pail West I' <br /> onsultant/Sub Contractor-`fe..c-kt%c,1egie� ZYte.-AddreSS Cir. , S-t-e.. � CityS$oclC+On Lic# Phone#�2.o9-Z3'�-O$18 <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# �PRESSURE GROUT <br /> ether: Grout Specifications: <br /> ;OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?DYES R/NO WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Nh TREMIE TYPE TO BE USED: 0 AUGERS IKHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: l6es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: tYOTHERDir4L t 1&s.4 APPROX.BORING DEPTHS&Ac- o►sf'ac 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �}. CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> :OMMENTS: PkoASd 1L 1=1nViy0✓1rV12W'�a►1 Si-Fa. AtSaSSrKtvt't �ydraKli� drYa.c-E DNsI� <br /> e r 66i t MKof ✓cwv%d Wo:tLw a w. <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 application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations, nd all applicable California State Laws. A <br /> gned x !r1 • Title/Company E r1 V, s Q Y'V. I��q r. L o vvxta-v <br /> int Name Dav d t`• Woo / ��az <br /> Date <br /> DEPARTMENT USE ONLY 7- <br /> ITE MAP IN UNIT IV FILE, ADDRESS: <br /> 'ORK PLAN DATED: <br /> )plication Accepted By cam` Date Issued /D2— Are azV AfA C AS <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 /> -rl7 M/( _%A1,AT1/Fr) r G.7 I ++-u. -4 A..yL -., ���: y_ � _ •i r i n in-,inn <br />