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PAY WELL PERMIT APPLICATION FORM SITE <br /> REc,E,V�i i TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> APR 2 9200 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> SAN <br /> PUBLICO HEALTH SERV AQUIN T)/ (209) 468-3449 <br /> ENVIRONMENTAL NFALrI;r,,,,', <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,Chaptgr 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Block 1 : bo �+� 6�y/ StVoj+%*610, s, Assessor's 1L <br /> WELL Location tA,r%Lr UYwr►j� t LIne,MKx1 Cross Street City 5{a�-k-}�✓� ZiP �152-�Z Parcel# 3Q•� o.t�o.��e <br /> PROPERTYOwner S�Q- 0.►+'o�c�a-� Address CityZip Phone# <br /> I s..►'+ X05 <br /> C-57 Contractor V IYov%*-Y. MV%( Address Zl�d A�alv►S Ave-. City LAS 4ra zip 11s�t ic#�L Phone.5to-565-467-(.0 <br /> Con or- wry /88 Fr••►+Lc. West 2.01-2-S-4-0$/a <br /> Consultant/Sub Contractor 7a_<-ti%nologie5.=NC•Address Cir• Sty. Z city5'ock-for% Lic# Phone# <br /> GIs Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Wi�EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> 1]PRESSURE GROUT <br /> 0 WELL# <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING n HOLLOW STEM DIA.OF BOREHOLE 2-" MULTIPLE CASINGS? 0 YES �O WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DI PTH OF GROUT SEAL g4h TREMIE TYPE TO BE USED: 0 AUGERS VIHOSE <br /> 0 AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: hes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING p HAND AUGER GROUT SPECIFICATIONS: `, <br /> 0 OTHER: VOTHERDiro.� I�KS1. APPROX.BORING DEPTHSu- 0-410-e— 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> r}- CONDUCTOR CASING PROPOSED? Irl A (if YES,list specifications here): <br /> 'COMMENTS: PIno.S� JL. E�v►v'ov�w►�N�AI si-} a AtSe-SSlvl�vl"t Iltidrak�icdiYeo-t- Pt+�S� <br /> loprik!lV, oil <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 Regulations, nd all applicable California State Laws. <br /> Signed x Tide/Company Eyw' <br /> W OP <br /> Print NameDI-V-' 01 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> II <br /> / L Date Issued y/cT/ l6�' Area O/ Cbs <br /> Application Accepted By D1'1 <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Oy o8 4 S� <br /> ation to sign permit Encroachment doc <br /> 9/27/00 <br /> C-57 WC -WAIVER C-57 Letter of Authoriz <br />