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WELL ERMIT APPLICATION F&RM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) U <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FEB 0 5 2002 <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 iE i�i re Alolbp'M $ n <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environ m��)(e�y�s'pr�s <br /> WELL LocationI SoLi,. K Cross Street CiParce��l��#w <br /> PROPERTY Owner 00 Address���I ���1 e✓ (1 City ZS��(Z�.taw; Zip �LO 1Phone#L i.�4A-- 8�3 <br /> C-57 Contractor ftPC+i�.v� mal_�Address*0Q ��k S'kee City i +>1o, Zip�14�04 Lic#� 38 1 Phone#S(b. z31.¢SSS <br /> Consultant/Sub Contractor r Co✓ool. 'onAddress[ Z6 (yla✓I _t ftVA city Sc r✓.L _-Lick Phone q111•Sbj.41g3 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED DESTRUCTION(choose type below) <br /> NEW WELL/BORING( PT)GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a a OVER-BORE <br /> a SOIL BORING# <br /> 1]WELL# PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z 1 r1• MULTIPLE CASINGS?a YES III NO WELL CASING DIA: <br /> p EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS_VOnP_ TYPE OF CASING: []STEEL p PVC []OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL I O o�! TREMIE TYPE TO BE USED: []AUGERS 10 HOSE <br /> AIR SPARGE )(PUSH POINT GROUT SEAL PUMPED: a Yes ](No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: I S"to R t . ?-- I; ��— <br /> OTHER: []OTHER APPROX.BORING DEPTH 100 C+ U BOLTED TRAFFIC BOX or (]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? no (if YES,list specifications here): <br /> 'COMMENTS: <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 Regulations,and all applicable California State Laws. <br /> A Title/Company f My Ifi Co�Ocara�l Irl ,--} <br /> Signed x Ana,t -�•�-•. � � a� <br /> Print Name Date Z� O Z— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I A,0-k l> S:b-&A - <br /> r <br /> WORK PLAN DATED: 2- 2 <br /> Application Accepted By <br /> C— Date Issued 9, /0 7- Area <br /> �p�^ Date Final Inspection By � #/�^^�`r�_ _Date <br /> Grout Inspection By — —� `� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED 7CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3so1 �s�'1 0� s <br /> 9/27/00 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br />