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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 /> 81ock V: boLAv%*4,A by Awrorw, Assessor's f <br /> NELL Location Ckw►�n¢l, U PRL WQloar Cross Street City StOck{py% Zip Parcel# 39A o-�' .61-yIJ <br /> IROPERTYOwner SGS 0. 0►L„�� Address CityZip Phone# <br /> 1 Se.in *OS <br /> V <br /> -57 Contractor IYONQ.y- 0 T-KL. AddressAal0.m5 Ave-. Cityl.a..1ro Zip,11STt.ic# 9L-4 Phone#510-$(6-j(eT(o <br /> Cor► or wry !88 Fr.►r,lc Wtst <br /> 3onsultant/Sub Contractor `��e.�rtoloyi¢ =NG•Address Ci✓. , S-t'*-. I City�ock�On Lic# Phone#401-Z3-1-0518 <br /> 3IS Coordinates:X 'Y Township Range Section <br /> NO RK 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 /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2-” MULTIPLE CASINGS? 0 YES 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 NOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ees 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ,` <br /> ]OTHER: (eOTHERDirtt. ?"5,4 APPROX.BORING DEPTHSu- aR'ac 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NA (if YES,list specifications here): <br /> COMMENTS: E.y%y i r py% lne yt+o.1 S i+4- <br /> r l Y i 1 0.K r b ltiYN a1 W a--t L y- so, 1 <br /> NOTE: OFFSITE INORINGS 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 Regulations, andp II applicable California State Laws. AAA -- / <br /> signed x f/ 4 Title/Company ESV. SQXV. IV 4 y'. L o t r <br /> Tint Name D0,\j 1 K• W O od► Date 4- ,��/�7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> MORK PLAN DATED: <br /> ��j • - e // <br /> +pplication Accepted By /d �� C� Date Issued y Areal <br /> rout Inspection By Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> ;OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />