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1 L/L�/LYJI�r 1 d:k7L L Jy4Gu 4 j t'it 1 H FLUUR H96L UJ <br /> WELL PkMIT APPLICATION FOR01 SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> plication is hereby made to San Joaquin County for a permlt to construct and/or install the work described. This application Is made In compliance with San <br /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> � I j Assessors APIA Z <br /> ELL Location ;kV �oL_,4 Ik-rnG�� �U�lCross Street K'9�'� city STOLK r "7l Zip D�Parcel# 17171 - D W-3 J <br /> tOPERTYOwner HPPI e d�ercgnq� <br /> 54t�c�"rzf�dr�e�s J4?J( Jv `<n6 l lcity J tvG�c{���Zip ��IJ�QPhhone l•�L'y 9� `3339 <br /> �ifC <<� / fG. 1 n � U,L 63�� <br /> 57 Contractor Glti� ,,,, �,:tr,q�dress l✓ l^r�Sc �3 Ci y It i/ i T Lic# <br /> / Oa k1j Lic# 11-3 <br /> )nsultant I Sub Contractor I M u ss 2101 lo City <br /> 5�•40"JOG> 2,3S Coordinates:X ,Y Township I N Range �o L- Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDRO CH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below} <br /> ',,SOIL BORING# (® V" 0- 0 OVER-BORE <br /> II Lo WELL# 0 PRESSURE GROUT <br /> ether: S l r'; fb fv_ " Ie rout Specifications: <br /> DMMENTS: Pre - ;"-It F n l <br /> 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA_OF BOREHOLE � N[MULTIPLE CASINGS?aYES NO WELL CASING DIA: <br /> EXTRACTION o AIR HAMMERIDRIVEN CASINGTHICKNESS Iota,, TYPE OF CASING: iJ STEEL 0 PVC []OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C AUGERS Q HOSE <br /> AIR SPARGE '*USH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: n OTHER APPROX-BORING DEPTH �C' �t• []BOLTED TRAFFIC BOX or STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED? NC, (if YES,list specifications here): <br /> OMMENTS: e 41 ALtia u 6c.:c <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNrr IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> lereby certify that I have pr"ar,9d this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinanc sRules afl ulations,and all applicable California State Laws. <br /> 11, �i <br /> fined x TitlelCompanY �'r•.•�-+ �c'��oG`5� <br /> Int Name r��e,,c C ��✓l Date ��12-7/ZOO <br /> DEPARTMENT USE ONLY <br /> CTE MAP IN UNIT IV FILE,ADDRESS: <br /> 'ORK PLAN DATED: 1n .. .. .� <br /> :pligSon Accepted By I ` Date Issued��- -Area <br /> out Inspection By ( � cM _Date `3 o Final Inspection By �l�-���c0y�____—Date <br /> astruction Inspection By Date <br /> )MMENTS/CONDITIONS: <br /> kCCOUNTING ONLY: AID# FA <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> $ -�°� 1p °I --11 S- I- I� <br /> -57 WC -WArVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />