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FILE COPY <br /> ti,5 WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> \O; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 SOF eL � bw <br /> (209) 468-3449 MW i U 3twi, 1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Vplirafion 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 na..-^^^-"'T ^`^^'"' """"""'"''e Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> // ,t /,//,4Assessors <br /> NELL Location .O1Z t ross Street�� � ,t1' A ZIP Parcel# /•/� <br /> 'ROPERTYOwner �I�. W �1Yr Address N/A City LmilOU � ZIP ��aa����''nnPhone# //�� pp <br /> -57 Contractof 04SC Af - 1Yl Iliy)G Address0(P Oy1'wC Gt& City C�11 � eZiP15L]Lic# vPhone# �3TI' '� 1 <br /> -onsultant/Sub ContractorSVO(Z ll1' yda LY/�lRoddress I a, ,71v l ty � 0 Lic# Phone# �(P (0 ' U <br /> ;IS Coordinates:X J✓�/f .Y N'� ,Township_Range_Section NR <br /> ORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROSE, OPUNCH,HAND-AUGER, 0 OVER-BORE <br /> 0 SOIL BOR G f I �e <br /> /JELL#_ '�IrtyV'ly 1rt�-I� ( a PRESSURE GROUT <br /> Other: , ` V / G ecifications: O'� 1 S <br /> -OMMENTS: Y G <br /> OrYtSV Iava farN D. l�l�I <br /> YPE OF WELLL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS U <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 11 MULTIPLE CASINGS?0 YES )(NO WELL CASING DIA: Z <br /> ]EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSPVLSGH. D TYPE OF CASING: 0 STEEL XPVC Il OTHER: <br /> ]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED: [)AUGERS HOSE <br /> ]AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Yes _ o (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: � h I IC/ <br /> ]OTHER: []OTHER APPROX.BORING DEPTH Y: I BOLTED TRAFFIC BOX or p STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED? D <br /> 3 (if YES,list specifications.h1er ): <br /> COMMENTSV r <br /> 5(v 1( M 5 !7� 10 Inc TOTAI 61Cm. <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 this application and that the work will be done In accordance with San Joaquin <br /> ,ounty Ordinances, Rules and Regulations, and all applicable California State <br /> /Laws. <br /> x ,(' (� Titte/Company L > s S MAI, n�. <br /> 'riot Name I SSI I I C, dkS Date O <br /> WL <br /> DEPARTMENT USE ONLY <br /> 31TE MAP IN UNIT IV FILE,ADDRESS: <br /> NORK PLAN DATED: ;2 —02 3.7•O - Rs: <br /> 1pplicadon Accepted ByDate Issued /0,2t`DZ Area 86�¢ <br /> Srout Inspection By­_ <br /> y Date Final Inspection B =•_ av 1­L';"Date <br /> )estnutlon Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cora <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST 0 INVOICE <br /> ,�Sa( d l 53 sR# l�3 S9S <br /> -57_ WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />