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PAY KA <br /> ECE(�`'FWELL PERMIT APPLICATION FORM <br /> SITE <br /> APR 2 9 Me MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> PUBLIC HEALTH SERVICES <br /> SANJUAOUIN COUNTY (ENVIRONMENTAL HEALTH DIVISION PHS-EHD <br /> ) <br /> ENVIRONMENTAL HEALTH DIVISIur, 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 /> 8lockZs 100--JA�VL 61 C-lYAKt, Assessor's 1L I <br /> YELL Location IMiwtr, �QKrorw�•Cl�r�r.a l Cross Street city 5l-Oek�"OYl Zip 95ZOL Parcel#_:$ o�.1rc c.�2d1 <br /> ,ROPERTY Owner SGC. 0.{+O_-_4aj Address City Zip Phone# <br /> -•� se..� X05 <br /> :-57 Contractor VIY•OWQ_Y_ .-AC.. Address 2110 A�0.w►'y Ave-. CityL.s.-J" Zip` gS7-kic# qL4 Phone#510-5166-+67io <br /> COW► or- ar-rk /88 FV'*.Kk. W.Lst <br /> onsultant/Sub ContractorTe.c-l%y%oloagieb,=nC•Addres s Ci✓• S1.4t. I CityS+oc +,Dn Lic# Phone#2.01-Z3^i-05!8 <br /> %.14T 0 <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# 0 PRESSURE GROUT <br /> 3ther: Grout Specifications: <br /> OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2-" MULTIPLE CASINGS? BYES 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 JKHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 9"Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: `� <br /> OTHER: [OTHER Dirmc� I?,As14 APPROX.BORING DEPTHSu- o4j6e 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Irl A (if YES,list specifications here): <br /> :OMMENTS: Pino0.5a. It <br /> 1cv�Vi�oYLW►QN�a►l 51' 4- AsStSSrv�tvt-t ��-ldra�it> <�c.� a�.fY��� DwS� <br /> r i r soil MK d ►�a wv�d w e.-t-� Y a v+� t c. <br /> NOTE: OFFSITE ErORINGS 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 app ication and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations and all applicable California State Laws. <br /> gned x ""�� Title/Company env• 2.'r V. NA L O �0''r- <br /> int Name Do-.4i of K WOO Date <br /> DEPARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE, ADDRESS: <br /> 'ORK PLAN DATED: <br /> plication Accepted By__zJ//it /���( Date Issued V 62- Area <br /> out Inspection By Date Final Inspection By Date <br /> struction Inspection By Date <br /> )MMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> u <br /> ' CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> E <br /> 0F7'y'110 .06d--76017 <br /> -57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />