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WELPERMIT APPLICATION ARM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location /(f 4(nX Al A/,1-r Cross StreetG /�'7 2 STCity 5>31r-"rY>A1 zip fCC�0ZParcel# /.J;`-0�-0/ <br /> PROPERTY Owner/TlIZM17G /1i6�4w CU Ad�ddress iPa/70X A 51AA1/` Ci�e4 Zip 7�IV Phone# <br /> C-57 Contractor 4Vk114I_ Address 3293 FVe-Itrl/0 City `P Zip�1YZLic#S //1Phone# /�-6�-7Z7�J <br /> / 00 <br /> Consultant/Sub Contractor 5�Go2 Address, /7 ,/tit O/ City aa'44 - LickPhone# AV'dX0f/O <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# 0 OVER-BORE <br /> ,WELL; f - OPRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIGATIgNS 6 rr r <br /> 0 MONITORING ,'HOLLOW STEM DIA.OF BOREHOLE 12 4 �MULTIPLE CASINGS?0 YES (NO WELL CASING DIA:_ <br /> XXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �F/`70 TYPE OF CASING: )!(,STEEL )(PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AAUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes [],N/,o[,(/�N�OTE: MAXIMUNj FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1414- CC <br /> H OTHER: p OTHER APPROX.BORING DEPTHBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / CONDUCTO CASING PROPOSEDv L� (if YES,list speciricalions <br /> *COMMENTS: <br /> y0 /� G✓/77f $'G/IL��1M <br /> ZO Yo 7 t /3s S SYL-Z, = a- " 4*1VO 641dCG A//77/- <br /> NOTE: <br /> /77`NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS."GO" s 30' <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,firules a d Regulations, and all applicable California State Laws. <br /> Signed x "W" Title/Company <br /> Print Name_ - /;e( /v Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES : <br /> WORKPLANDATED: fhg,, SC2::fl 0Z <br /> Application Accepted By Date Issued � a� <br /> Grout Inspection By ��tAA -T Date Final Inspection By —safe <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# rer« <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35-0 ( I 4S9-0o 1 5-30-331 (a It D0- 1 SR# O <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />