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" 'AY'MENT <br /> 'IECEIVED WELL PERMIT APPLICATION FORM SITE <br /> APR 2 92V� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> PUBLIC HEALTH SEROCES <br /> 'NVIHONMENTAL HEALTH EIVSIOP' 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 /> 13104.14311 b o N KjC0( b y As.ro rq, Assessor's 1L I I <br /> /ELL Location Mi*y%-r, U PRI-, i C4.a K►ul Cross Street city Stoak..ton Zip Parcel#_ Q.e 0. a c�n2e` <br /> ROPERTYOwner SGE- 01,'i 04.4-4QJ Address City Zip Phone# <br /> So.'^ /I 405 <br /> -57 Contractor Vir-OMQ.Y- Z"C. AddressZl10 Ad0.mS Ave. Cityi.4-11ro ZiP-jjS*jLic# 9Z4 Phone#510-S4.6-4(o7-(o <br /> CoA or' d►Y /88 FrAYtk. West <br /> onsultant/Sub Contractor -TG-c4An01ogiea lrtG•Address Ca✓.� S-t't. I City:S+0c,k+0r% Lic# Phone#.Z0°I'Z3'`1-oSlB <br /> IS Coordinates:X Y Township Range Section <br /> 0 R 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 /> JMMENTS: <br /> 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> vIONITORING 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 /> 1APOR 0 MUD ROTARY DEPTH OF GROUT SEAL hjA TREMIE TYPE TO BE USED: 0 AUGERS I HOSE <br /> >IR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: �"Ses 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 3OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> )THER: 5(0THERD;rL6t PA5,4 APPROX.BORING DEPTH3u- J-ac 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> .��}}... <br /> CONDUCTOR CASING PROPOSED? HA (if YES,list specifications here): <br /> JMMENTS:_NO-SQ it EV%Vir0V MQjA+,1.1 Si-I-e. Asst-SS►titt-Vt-t ' In�rdro�Klic. o(IY�c}- DttiS� <br /> r i V• i t o-vtd ra whd w a-t a v a w. 1 c. <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 /> 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. I <br /> Y <br /> ned x l� Title/Company EYl�/• Q Y V. �^, O YLOI O <br /> it Name O.V 1AI_ K. woc'j Date <br /> DEPARTMENT USE ONLY <br /> -E MAP IN UNIT IV FILE,ADDRESS: <br /> )RK PLAN DATED: O <br /> Iication Accepted By �A--►-o Date Issued 102—�(/OZ Area Apt OS <br /> Lit Inspection By Date Final Inspection By Date <br /> truction 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 /> TO/ . '-F3 Y61 4e a 1 QY (,I U <br /> 17 wr -WATVF(? (_F7 I o+tor of 2r.m:+ �� ria a,.- ni07/nn <br />