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1 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <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 /> ;oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> I&loc.kC: looKNAAA 6,1 C4—Kt, Assessor's + a <br /> NELLLocation Lk&v%KA%, Atsv-orw, + Wa..b4-v Cross Street City StO�-�O✓► Zip Parcel# S" aT`��e <br /> 'ROPERTYOwner SGe- "—Address CityZip Phone# <br /> `) S.r, X05 <br /> -57 Contractor V 1►rov%Q-yC I.N►C-• Address Z I IO Xdo wiS AV2.• City L.s�►'o Zip %1STA-ic# qz1 Phone#510-S66-4loo <br /> Con or o►►--tk 188 Fr•►nlc- Wtst <br /> 3onsultant/Sub Contractor ` gie •= detok�OLic# Phone#ZGt'Z3 �-o$/8 <br /> Cit � n <br /> 31S Coordinates:X Y ,Township Range Section <br /> NORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# �OVER-BORE <br /> 0 SELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z-" MULTIPLE CASINGS?0 YES �O WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DE PTH OF GROUT SEAL Nh TREMIE TYPE TO BE USED: 0 AUGERS J(HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p'i'es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: [OTHER Dirty ?,&.54 APPROX.BORING DEPTHSu- BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> .��}}.. CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> *COMMENTS: P1no0.Se. ll. E�tVi�I.OrtYNQ,v��o�( Si+g- ASSe-SS►'tne►n.-t - �yatrc►vz(�c. , Ol1Y�ct" D1ti5� <br /> V I soil 0.V101 Y p L,.v%ol W 0.*lZ e <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulatio , and all applicable California State Laws. , A I <br /> Signed �, 71 ` tk�- <br /> Title/Company �'^`► �2ry IV 1 q r 7, C O✓IOIQY- <br /> Print Name DO.V110k K N O C V, Date Zo — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By—gkDate Issued��� D 2 Area 6 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED7 CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 9/27/00 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />