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I WE�d PERMIT APPLICATION PORMSITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION PHS-EHD 1JILAr T lv,'+ <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ., APR 18 20 6FV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andfor install the work described. This application�S��riad��n.compliaiic�w n <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin un Public Health Services,Environrrierital!iealtii blvisibn. <br /> [X VC 1Y // Assessor's <br /> WELL Location I� i Zve•�Da Cross Street City �YcM ZipQA07 Parcell <br /> PROPERTY Owner C67 o 7-',5;64 414A) Address Lits/V 47 City s]�+x�l + Zip ..2c72 phone#C�°9)93�-903 IF <br /> C-57 ContractorGA!4a �fr��a4 ti!/F��yI74 Address 450 /70u•P IfOgal City E�i/�eL zip 9ySS3Lic#6S6�TPhone#CQ�S)3I ,S 7 I <br /> Consultant)fttrtirWQfkrn Gd-F _Address J38eo --Re4nntf City /4rvr�Lic#, Phone#CS30��66' <br /> i <br /> I <br /> GIS Coordinates:X Y ,Township 2 ky. /h Range Section 2 <br /> I <br /> WORK TO BE PERFORMED. I <br /> I BORING(CPT,GEOPROBE,HYDROPUN'C HAND-AUGER,OTHER`) Q DESTRUCTION(choose type below) <br /> $'SOIL BORING# <br /> [] ' J B OVER-BORE <br /> a PRESSURE G <br /> ROUTWELL# 4 <br /> `Other: If SQAStir �. �w�►+Yr3w+� Grout Specifications: <br /> / <br /> COMMENTS: CPT 7k, /l/S Z0o1 gfeoVh. 47,61 J+ AZd ,,,,4 te.<r7yeh a�✓.�r gtcr4 aft/e. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE /" MULTIPLE CASINGS?a YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: []STEEL O PVC BOTHER: <br /> i <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS p HOSE <br /> E)AIR SPARGE I PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> []SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS: <br /> POTHER: CpT Q OTHER APPROX.BORING DEPTH l iFs,�eef 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> C N UCT <br /> CAS PR SED? (if YES,list specifications here <br /> / )*COMMENTS: "f !" ' vGG <br /> r` <br /> NOTE: FS]TE BORINGS REQUIRE ACCESS OR ENCROA_HMENT PERMgS. j <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 Ordi nce 0 Rules and Regulations, and all applicable California State Laws. / <br /> Signed x /+ Title/Company <br /> Print NameCG t-Gl�+^C1 Date -Lel'oI <br /> DEPARTMENT USE ONLY nom' <br /> SITE MAP IN UNIT IVI;FILE,ADD ESS: <br /> WORK PLAN DATED: �D <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By to <br /> Destruction Inspection By " Date <br /> COMMENTS J CONDITIONS: <br /> ACCOUNTING ONLY: i AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'a BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 350 <br /> Id .�oIi4fvro SR# <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit ✓E=ncroachment doc✓ 9/27/00 <br /> E0 3DVd dOO-12 HlaI2 £EbEE9trE0Z FSS CZ 000 151f02 <br />