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WL-LL PERMIT APPLICATIOWFORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MITIGATION <br /> Met <br /> L HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 , hird Floor, Stockton, CA., 95202 <br /> rZ� (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 <br /> San Joaquin County PublicHealthServices,Environmental Health Division. <br /> WELL Location 13ct S. Ce-ri' e L 5k 1�c..��: City �t 34611 Zip�_ <br /> Assessor's <br /> Cross Street ` �Z, Parcel# \�1'�VO"1Z. <br /> PROPERTYOwn�e)rt�¢Wpn�1 tT�telo� Address li %cairmt a1 a!J citySA� p�CA Zip Phone#�Q +��O�Z"�(o� <br /> C-57 Contractor V+W ��L�/�t�n't Address Qo ZX, �I � City 1SW61A Zip p OI Lic#7z0q16Phone# 1�'V1137- <br /> Consultant I Sub Contractor x l R_ Address3bn k[I% ye— 0) City # ic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> '-IEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 1]SOIL BORING# 11 OVER-BORE <br /> WELL# n PRESSURE GROUT <br /> 'Other Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS q <br /> PK,MONITORING �' OLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS?[I YES 0 NO WELL CASING DIA: <br /> EXTRACTION []AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ;PVC Q OTHER: <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 3/ ' TREMIE TYPE TO BE USED:AUGERS 0 HOSE <br /> U AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: JSes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATION'S: We <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH 3V S 7 OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Vkb _(if YES,list specifications here): _ <br /> -COMMENTS: MQ 06,KO_!T <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company—-�TA'tt SG►�+��t'Sisacs?-- <br /> V� Date S <br /> PrintName 5 i` Z7 l0 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Ce.1+C1-,-- - <br /> WORK PLAN DATED: U I/1 0 ( <br /> Application Accepted By <br /> QO-� � j°tYDate Issued 1-- 0 Area . <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS ICONDfTIONS: — <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMfTI SERVICE REQUEST# INVOICE <br /> i <br /> 0111L1-2,'& o L9 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> E0 39Vd a0019 H13I3 ££VE89VGOZ TE=£Z 000Z/b0;'Z <br />