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-- WELL PERMIT APPLICATION 1=64M SITE <br /> i � � � UVV Ev MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> MAR 2 2 2004 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ' <br /> P' -i',,"1T/SERVICES (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 /3q �Spwrd �nFTrR Sr2EE ' Cross streetVrestjwG�N S1 City Si 6cKTa�J Zip �I52a2 Parcel# ;3:7- 3pb-022 <br /> PROPERTY Owner Crl-Y of S7-o,-_X ronl Address 425 4. r>.n)mw STOeercity STOCK-1-6n1 Zip552.0? Phone# (2ocl)q3:7"94,99 <br /> `" (ZINC No <br /> C-57 Contractor (A,x.ADr OAL.LIA)(i Address 3(v3Z om[:c. C.14U-LC City Co noVA Zipq5�42 Lic# Phone#(2/lob OY-I(Y9 <br /> 04"o <br /> Consultant/Sub Contractor SECD2 /NTE 12/ 1}' lM t-L Address 3bt7 KIL(2DleE SaIrCIOD City Cb12D0Yf} Lic# Phone#0116) <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') []DESTRUCTION(choose type below) <br /> 0 SOIL BORING# o OVER-BORE <br /> 'WELL# S (tjcLLovJ-,jre fF}y�(,�►2) _ flPRESSURE GROUT <br /> 'Other: Grout Specifications: (0t,)1Z 4 11 E Po KT CE-ynEfSi- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A„ <br /> $MONITORING FOLLOW STEM DIA.OF BOREHOLE 12" MULTIPLE CASINGS?[]YES ONO WELL CASING DIA: <br /> 0 EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: []STEEL APVC 0 OTHER: <br /> Q VAPOR []MUD ROTARY DEPTH OF GROUT SEAL' Zb�" LIIp TREMIE TYPE TO BE USED: p AUGERS XHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> [I SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: PENTbN ITE o- P&CV►_M ) r CM EN T <br /> [I OTHER: 0 OTHER APPROX.BORING DEPTH v64' — CO®l BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 40 (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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord* nces, Rule and Regulations, and all applicable California State Laws. <br /> Signed Title/Company STW' FY"JGWEERA-aDA Lt"—IEgA'tT16x3f+L <br /> Print Name L-m C't _Date 32� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 139 Sn lr+I , e_&_4e�y <br /> WORK PLAN DATED: Ju Y1 e, 24 Z60 3 Addiend t)M +0 work 191,14_A* 1 o .bar :30; 266 3 <br /> Application Accepted By V je,+6 Y,i L Y Date Issued_Mar&4i 2-Y, 700 l Area._/4S 9 <br /> Grout Inspection By. Date 3 O Final Inspection By .L�-t/21f�-/i[c L /(.� ate— 1 I 1 0¢ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -35401 P 9q, 03 . 00 SR# 00373 ) (, j <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />