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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 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 /> ioaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Pµbli,- Works P-1�9�k-t of- Uj Assessor's 1L 1 <br /> NELL Location(aJ.,be•r,C.I o"Ke 1. Mi.-97r rS�Cross Street City Zip Parcel# SeA O�f�o�c-y1e� <br /> S+an tslwwi��}K V o✓a <br /> 'ROPERTYOwner SGE. 0.- able-40- Address city Zip Phho�one# <br /> -57 Contractor_ G P eAq � � 4 Address_+ City 4% 2 . ILic#� 7 Ph& s/ <br /> ,-Condor 188 Fr066%k— Wtst <br /> oE1e •Address Cw% Z <br /> Citvaoc +0r% Lic# Phone# 2.Og;onsultantlSubContractor 'T�eIrm <br /> SIS Coordinates:X Y Township Range Section <br /> NORK 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: r <br /> YpPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS C ` <br /> ]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z. MULTIPLE CASINGS? 0 YES ff"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 14h TREMIE TYPE TO BE USED: 0 AUGERS JKHOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: [R"Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: `' <br /> OTHER: RVOTHERI)ir0 I�Ksk APPROX.BORING DEPTHSu- cxk^e- 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AIA (if YES,list specifications here): <br /> COMMENTS: Plno.-se 1L, <br /> �} Si+&. AtSeSSvstietn"�- ' lnyo�ra.K�ic.� akiy-a-c--t- Dt&s�% <br /> Y1 ✓ soil 0.KA YDttiV�ol V�I0.fiQ V' 0.Yv� ,L �NGYOALL.rha.Kf QYVKI� ca.TCA��d�• <br /> NOTE: OFFSITE EYORINGS 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 Regulati ns, and all applicable California State Laws. C - I <br /> Signed x � V iVl <br /> k, Title/Company EVN ✓'ovr�. M+, d <br /> 1 � V«-c-s � ��ftQfi- <br /> Tint Name VAV�A h• W o 4>01, Date "g 8 D 2— <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE, ADDRESS: <br /> NORK PLAN DATED:// / ,/ ^ o <br /> application Accepted By� Ki�tL}t_ Date Issued 7�/�2 Area Al �T l OS <br /> 3rout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> E- <br /> PIE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />