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1 WELL rtERMIT APPLICATION FOk:�1 <br /> SITE <br /> 23 p�12:36SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> 03Sf ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 price <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 mde m y <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 /> NELL Location C��c?v S`t c�e e Cross�treet w oma„_ CltyS�o<AC�- Zip�S Z-1 Parcel# C-�`t -� <br /> PROPERTY Owner C��j 211, ��r IL 1,i-Address e. C -car 6r- ,.;c,,, City J4;� '. Zip S ZA j Phone# C'(3� -g 3� I <br /> V W U ��: ' 0 U J �1 b Cl ,CJr �S� '1 Z\)' <br /> C�7 Contractor it i_ Address ty Zip/ .L Lic# Phone# <br /> 'Lo sulLaoi— f�ubContractorl����V� ;CQ �tc�,y�;cSAddress } 1 1�^ St City Vcrt,trf"')Lic# — Phone#2,0`)SZ2,141)9 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> $WELL# M�1 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: SQ Q Vo 3 \�1, W Q d- Ll vZ W � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> it MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES ONO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC p OTHER: <br /> I]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. a AUGERS a HOSE <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING a HAND AUGER. GROUT SPECIFICATIONS: <br /> a OTHER:_O OTHER APPROX.BORING DEPTH . a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> c _ f CONDUCTOR CASING PROPOSED? (if YES,list speaficatio s here): <br /> *COMMENTS: 1 C� `C c G�1 V�P/� W P <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 anc I I and Regulations,and all applicable California State Laws. `, l <br /> Signed x V� Title/Company -\V�� "c -,-j \)°`W 2� l-11-� <br /> Print Name &o UQ -c\-1 -j Date C)-'3 <br /> DEPARTMENT USE ONLY L/ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: E C /ev lex,-, Sve/C <br /> WORK PLAN DATED: 27 e 0 O0 Cllbt&64C � 4oYekta✓k1 ot2Z <br /> Application Accepted By � v`rs�� _ Date Issued -3 Area 14J-3 <br /> Grout Inspection By. Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 mo gy pO O/ 17// Cl —'�, 9 -31,0,3- SR# 06 6122 <br /> C-57 WC--WAIVER.— C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> E0 3�Jdd 60073 Hl-IA EEbE89bG0Z 95:E1 T00Z/8Z/Z0 <br />