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0 22���� D WE� PERMIT APPLICATION RM SITE <br /> RECE MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT W <br /> 2001 <br /> DEC 2 0 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 458-3449 <br /> NON-REFUNDABLE PERMIr 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 Oevveettopment Title,Chapter&1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> m <br /> WELL Location /'lam VI l b w Croays Street ity S � Zip�rzf Panxl —�0� V <br /> 11 ,,��,,yy IUlxr�7� L,f�CL1f-( / <br /> PROPERTYCw arl33 Ol'S7PagVX)Z/�Srgrew 7379 NGN+1'!t/N L)t City -S)ZV ZIP�1�Phone# <br /> C-57 Contractor /�9dA14D 6vL // C" 7IA,,d��d,,ressd37 Jlrn-w/�� City Ljc# �Du�Phone#1� Y67/° . <br /> Consultant)Sub Contractor kV �s V Address fJSZ 5ttC V &2 City�Uak6d ZL Prone#La 9 �f/o7/o/6 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> a NEW WELL/BORING(CPT,�GEOPROBE,HYDROPUNCH,HANG-AUGER.OTHER-) OVER-BORE <br /> (BOIL BORING# lei TU TNii`GI'MB'/'+e7> iN�An��D7F.B0�UNG$/7z— 0 <br /> WELL# a PRESSURE GROUT <br /> •Other. - Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE _ CONSTRUCTION SPECIFICATIONS <br /> o MONITORING i]HOLLOW STEM DIA.OF BOREHOLE 7-r MULTIPLE CASINGS?0 YES 0 NO WELLCASING OIA: NA <br /> U EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS N"+ TYPE OF CASING: U STEEL a PVC OOTHER: <br /> 11 VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL__S TREMIE TYPE TO BE USED: ]]AUGERS U HOSE <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: O Yes 1]No (NOTE:: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: OW-L~ Cz7v�7- <br /> a <br /> a OTHER: Il OTHER APPROX.BORING DEPTH . 1]BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROP OSED?�(if YES,list specifications here): <br /> *COMMENTS:— Sct(, r3dfGt�S �✓� Seca L- 6:�,+8 $� Lur.ckT-n.-� <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi es, rtes an Regul tions, and all applicable California State Laws. <br /> Signed x <br /> Tide/Company ///p <br /> Print Name /20 <br /> DEPARTME--((NT USE O�N}L�Y�� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5 135 Cti C Ed <br /> WORK PLAN DATED: <br /> `V <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By i L Date d Final Inspection BY �- y <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> QACCOUNTINGY: AID# <br /> INFO AMOUNT REMRTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST i INVOICE <br /> 1 n-1 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />