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`APPLICATION F0 M SITE <br /> MITIGATION <br /> jr n^ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> PC. ,ryry ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> I'�V'1hE�'vr';ri`i i I"i'A Vii; 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> fi';Fl?"{!` -R°BICE (209) 468-3449 <br /> NON-REFUNDABLE pERmIT EXPIRES 1 YEAR FROM DATE ISSUED Iieatlon is made In compliance with San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental <br /> Health <br /> e lltthSDivision. <br /> 34�r1�o A. P �_ City o1!�CK�6Y� Zip 9 526 Parcel# I'll-07 '33 <br /> WELL Location ! �� a� � Cross Street <br /> r� 1 S ruc�"w� drt�ss 3437 <br /> I So.a rQ (VFW 54- I — zip S? Phone# <br /> city -g 3339 <br /> PROPERTYOwner pX(IfX Nero�UlLo I / ' `�5 / <br /> City— <br /> G-57 <br /> ity 5 CoC�T611 Zip 97 Lic#512Z" Phone#ztp)-' J- T Z <br /> ar r E}� `6LlAddress 23 �I�AiAl <br /> -r7Contractn <br /> Address 212 Phone#925�-('3 � <br /> t/Sub Contractor <br /> onsulta Pa�`3CSY�� 5°` BSD 6E �� <br /> C-;IS Coordinates:X •Y <br /> ,Township Range J Section <br /> WORK TO BE PERFORMED: Q DESTRUCTION(choose type below) <br /> ' NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q OVER-BORE <br /> I]SOIL BORING# [,PRESSURE GROUT <br /> fGrout Specifications- <br /> 'Other- <br /> G ^ ' <br /> Other: ij'P`�� <br /> COMMENTS: <br /> TYpEOF WELI INSTALLATION TYPE <br /> CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING HOLLOW STEM DIA_OF BOREHOLE 0 MULTIPLE CASINGS?(]YES NO�^[WELL CASING DIA: <br /> `EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS 5r h O TYPE OTFFCASING.G.DTOSTEEL <br /> E USEC7PV�a GERSOTHER Q HOSE <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: XYes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: 17 OTHER. <br /> APPROX_BORING DEPTH 70 -k <br /> , CONDUCTOR <br /> ,ICASING PROPOSED? N0 (if YES,list specifications here)-_— <br /> 'COMMENTS: ( s, ( �Q�Z- <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 /> hereby certify that I have prepared U is application applicable a work California ll be done in Laws_ accordance with San Joaquin <br /> County Ordi nces„f� sand Reg �� ��.363a �at.r5�vt5 <br /> �y/, Title/Company <br /> Signed x k Date �`�•3 i 206 <br /> Print Name - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> L <br /> V 1 C 06 Area <br /> 'qtate Issued <br /> Application Accepted By .-c <br /> Grout Inspection By Date <br /> Incl Inspection By Date <br /> Destruction Inspection B Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# r <br /> PERMITigERVICEREQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE362 <br /> Z <br /> 9/27/0 <br /> C-57 WC -WAIVER C-57 Letter of AuthorriZatio sign permit Encroachment doc <br />