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• r <br /> WELL PERMIT APIPLICATION FORM SITE tPulry <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 r <br /> of (209) 468-3449 Q FF I !OGS <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 ISan Joaq AV eoLnty Public Health Services,Environmental Health Division. <br /> 1' Assessor's <br /> ELLLocation Bridgeport a 1 DevelOpCrossStreet Charter WaCity Stockton Zip 95206 Parcel# 163-0060-15 <br /> PROPERTYOwner San Joaquin Vally AsAddress 2333 San Ramon Val:* San Ramonzi 1 9490:4one ' 840.66'77 <br /> C-57Contracto�ectrttm Fxi 1 nrati�ress 9465 m WI6Wi}nh Dr City Stocktoteip 9520iic#512268Phone# 209-465-8712 <br /> Consultant/Sub Contractor Geomarrix Con. Address2444 Main St, #215Ity Fresno Lic# Phone# 559-264-2535 <br /> GIS Coordinates:X a70 55-a4' ,Y 1 210 18.65' ,Township 1N Range 6E Section <br /> ORKTO BE PERFORMED: <br /> NEW EL /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') U DESTRUCTION(choose type below) <br /> U SOIL BORING# []OVER-BORE <br /> *ELL# TV—A , TW—B, ,TW—G TW—D, NPRESSURE GROUT <br /> •Other: 6d $, T6d-$, & Til-6 Grout Specificatio s: ' <br /> COMMENTS: A <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING it HOLLOW STEM DIA.OF BOREHOLZ'8•' MULTIPLE CASINGS?0 YES :R NO WELL CASING DIA: 2" <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S ch 40 PV6`YPE OF CASING: 0 STEEL 6PVC U OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEACL'0 — 11' bgREMIE TYPE TO BE USED: I¢AUGERS 0 HOSE <br /> 0 AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OSOIL BORING 0HAND AUGER GROUT SPECIFICATIONS: Cement/Bentonito Mix (< 5% Bentonite) <br /> 0 OTHER:—H OTHER APPROX.BORING DEPTH 30' bgs 0 BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (if YES,list specifications here): <br /> — <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 tt) t I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County <br /> `Ordina s, Rules an Re ula 'o , d all applicable California State Laws. <br /> Signed x\\ / Title/Company t0.Gv Elt/ 7 G(4 57/CK� 1 r <br /> Print Name wt0 G- �o U�"I' ✓ Date A '7-3—Cl _ <br /> gDEPARTMENT USE ONLY �y <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /�� 4/' A4':Z � `�/~�' cocao" <br /> WORK PLAN DATED: - L W te.T"" - T O.C//A-- ICI 0/ <br /> Application Accepted By « Date Issued 7—/2 -o i Are,—"-691 <br /> ram u <br /> Grout Inspection By Date Final Inspection By Date-- <br /> Destruction <br /> ate .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 REOUEST If INVOICE <br /> L90 MW 8 i / &' 7.5'01 SRO 26 3V <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment clot_ 9/27/00 <br />