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252— <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br />UNIT N <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES I 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 Tltie, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />S <br />�1S Zu`Assessor's <br />HELL Location\ Cmss Street Zip Parcel#l3 S <br />PROPERTY <br />Owner Seo Y. F Address Z� �`�y o a�r�� City S�o� J.� Zip sZ`��Phone# <br />�s��a, �Sb4I 1Z��10� `l\�O X11-�{l 00 <br />C57 Contractory � � Q M\� —3, -Address � b ��% � ` b City Zip Lic# Phone# <br />.�� v c Y� )d�A � — -Z S Z Z - <br />Consultant / Sub Contrac, tor °�c'A Address �� t City Lic# Phone# <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />[] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE <br />*WELL# '�'-\N --1 PRESSURE GROUT <br />"Other: grout opeclncauons: <br />COMMENTS: a– (�_ : �- --) +>l 1- O C <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MMONITORING 0 HOLLOW STEM DIA, OF BOREHOLE MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC D OTHER: <br />[] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 1] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />0 SOIL BORING 0 HAND AUGER, GROUT SPECIFICATIONS: <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSE�Dp? (If YES, list specifications here): <br />*COMMENTS: C.CTZj �) ��L Uyo` _, <br />NOTE: OFFSITE BORINGS 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 Re ulations,�and all applicable California nState Laws. <br />Signed x •� _ �- l ` __TiilelCompany " Cc, S V <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED:_ --) <br />Application Accepted By, <br />Grout Inspection By <br />Destruction Inspection B <br />Cr)MMFNTS I CONDITIONS: <br />Q 1 2L`1 <br />DEPARTMENT DISE ONLY <br />F Date Issued <br />_Date O *Final Inspection By <br />Date <br />u� <br />ACCOUNTING ONLY: AID# <br />C-57 Letter of Authorization to <br />PE CODES <br />FEE INFO <br />` AMOUNT REMITTED <br />CHECK # <br />REC'D BY D <br />PERMIT! SERVICE REQUEST # <br />INVOICE <br />I�GZl8ZJZO <br />C-57_ WC= WAIVER____ <br />C-57 Letter of Authorization to <br />.rgn p�1it_ <br />encroachment doc <br />y/ t I /VU <br />ce ?JGd <br />�DO�� HlaI� <br />EEbEE9ti69� 95 EZ <br />I�GZl8ZJZO <br />S <br />z <br />