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f <br /> `off WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES M1TiMITI A <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 /> pplication 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 /> )a uin County De t} <br /> o meat Tie Cha ter 1 15.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> q 4-.+- k- - X6 Assessor's 1 <br /> FELL Locatian� e S/a/i�c5aw+ Jo-% �a c K cSt• CrossStreet �ar k City S+a4k�ro to Zip °tS�o Z Parcel# <br /> ROPERTY Owner I i Qinressd: p � City C t`+1" Zip V�none# <br /> ,r ��S <br /> -57 Contractor Vivon.Lx. =Vlc... _ Address City�,Gwv�afy. Zip`I75ic# °IZ-4 Phone#S!Q-568-704. <br /> CPNCAOY E.caV+k I$$ rvda.ttilC Vj&J I <br /> onsultant 1 Sub Contractor "TQ c_km o 1 o i a 5 THc.Address C i r. Su' T City Sf 0CV_+0nl_ic# Phone#2-09-Z3 -.0-SIS <br /> 1S Coordinates:X ,Y- Township Range Section <br /> "ORK TO BE PERFORMED: <br /> EW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> It Q SOIL BORING# [I OVER-SORE <br /> 0 WELL# 11 PRESSURE GROUT <br /> Aher: Grout Specifications: <br /> 3MMENTS. <br /> IPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE 2.1. MULTIPLE CASINGS? [I YES R�40 WELL CASING DIA:. <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS 1 j A TYPE OF CASING:' 0 STEEL 0 PVC p OTHER: <br /> VAPOR Q MUD ROTARY DFPTH OF GROUT SEAT. N A TREMIE TYPE TO BE USED: 0 AUGERS & OSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: tales p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Olt BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: $OTHER Di►rc`f RAIL, APPROX.BORING DEPTH 15+-'c{o, p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROP SED? l A(if YES,list specifications here): <br /> OMMENTS: C,0-(-Y0a_CA-v q.l„ vitii-� Gt, kC_Ll <br /> N E: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> junty Ord'na c is les a d gulations, and all applicable California State/Laws. <br /> lned x Title/Company <br /> rit Name Date <br /> DEPARTMENT USE ONLY <br /> TE MAP IN UNIT IV FILE, ADDR SS: �Q � N. 5" , yam <br /> ORK PLAN DATED: cj <br /> plication Accepted By c Date Issued- [D I Lp I C��� Area <br /> Dul Inspection By Date I— Final Inspection By Date <br /> struction Inspection By Date <br /> )MMENTS/CONDITIONS: <br /> ,CCOUNTING ONLY: AID# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK/# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 57 WC _------WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 9/27/00 <br />