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WELL PERMIT APPLICATION FOr,'M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (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 andlor install the work described. This application is made in compliance with San <br /> n. <br /> Joaquin County Developments Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Envi�rlonment�asessolrsth DiviYsi 3 <br /> �l�S� y� lr..,�a C' 9So'-G/Parcel# jS ,J�Lq <br /> WELL Location // Cross Street r r• id Zip <br /> PROPERTY OwnerllG4,.dod Lk' 4jr�e- °.ddress /OSD 50"411 kr— r�ity _;��.O of Zip9l 30( Phone#L2L9)yf7-Fi�73r <br /> C-57 Contractor 5c&dd :P , Lr T^rAddress 3x32 Ome c. �t."JL Cityl24-a4At" P--eL 7`Ql- -ILL <br /> 57a 70 Phone(q/4 34'/l� <br /> Consultant/Sub Contractor ATC s}G$OcjAS Address 111-71 neP)r-. A0$8CityMcd•5+11 Lic# Phon.<2Cj 579-22�I <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type beIcW) <br /> ®.1 W WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 1]OVER-BORE <br /> p SOIL BORING# PRESSURE GROUT <br /> &WELL# I''t°J I m IV 1. l w6� H w'1.N w`6 911 Lo n <br /> *Other: Grout Specifications: t Lilt Ar av"Y <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,, r, <br /> ONITORING �LLOW STEM DIA.OF BOREHOLE " MULTIPLE CASINGS? 0 YES &<O WELL CASING DIA: �- <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 10 TYPE OF CASING: 0 STEEL jI PVC []OTHER: <br /> a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL !�/ TREMIE TYPE TO BE USED: GAUGERS p.HiOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: gyres 0 No(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: 1 + <br /> F OTHER: 0 OTHER APPROX.BORING DEPTH GS � 9-BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A10 _(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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> �i-ill�,.n 1_J7, Title/Company h� cT A-s5Q� afico �t' rn'� <br /> Signed x I I� p <br /> Print Name �T?L1.VI YID- T-Kill^Se-`f Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: OZ <br /> IsArea <br /> ! Y�O <br /> 01�CV� �Q�C <br /> Application Accepted By Date sued <br /> Grout Inspection By <br /> Date Final lnspectio By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> ECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2--'7o/ W_ - 6 t) 04 9 / b oz o f �$ <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign permit_ Encroachment doc_ 9/27/00 <br />