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C"N U HE <br /> WELL PERMIT APPLICATION FpMog S.ITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEA -11 , ALTS�cEs <br /> `ENVIR�]NMENTAL HEALTH DIVISlQ UNIT IV <br /> - <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NDN-RFFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUSD application is made in compliance with San <br /> gppfication is hereby made to San Joaquin County fora permit to construct andlor install the work described. This app _ <br /> ioaquin County Development Title,Chapter 8-1115.3 and the Standards of San Joaquin County Public Health Servir..es,Environmental Health Division, <br /> G�k O F ,S�oc3�C�Ca n <br /> Assessor's <br /> NELL Location W O� Sac <br /> Cross Street <br /> -city Sir,- o,.. Zip Parcel# <br /> I� PROPERTY Ownar e-t'k n Address _ Pham# <br /> o c� --- --_ . <br /> )/ 1 - <br /> G.57 C:orttraokor J" �U Address 'P ��jOx "`7��=`" C;tY. s p ll� Zi,�t-=moi" o D. .r_ne# <br /> F "���. �S .] Lic# "` Phone#Z 0 1 S Z,Ly I <br /> Gonsulta t I Sub Contractor n ��Cs+� �*' ddress O tY <br /> G15 Coordinates:X Y Township Range. 5ectian <br /> WORK TO BE PERFORMED: below) <br /> elow) <br /> NEW WELL f BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-)" [I DESTRUCTION(ci+aoss�OVER-BOREatype b <br /> I SOEL f30RING;# �i�C]?�1 p ro�P _ PRESSURE GROUT <br /> ! 0 WELL# <br /> Other _ Grout Specifications: i <br /> COMMENTS: <br /> TYPE"OF WELL INSTALLATIDN TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING d 0 <br /> HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? "YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMERtDRIVEN CASING THICKNESS TYPE OF CASING: ,0 STEEL 0 FVC. ]]OTHER-- <br /> 1] <br /> OTHER:1]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. Ii AUGERS 0 HOSE <br /> Q AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 Na (NOTE: MAXIMUM"FREE-FAI~L 17EPTH is 30'} <br /> SOIL BORING "0 HAND AUGER GROUT SPECIFICATIONS: " <br /> 1 Il 07HER; n OTHER APPROX.BORING DEPTH . 0 BOLTED TRAFFIC BOX or 0 STOVE FIFE " <br /> CONDUCTOR CASING PROPOS D? (if YES,List specifications here): <br /> s *COIJ MENTS: S.'— VJ <br /> } NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THEUNIT Ill INSPECTOR h8 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> l hereby certify that I have prepared this application.and that the work will be done in accordance with San Joaquin <br /> County Ord'LpV and 5eVations,and all applicable California State Laws. <br /> Signed x Tltle Company_ <br /> Date d�" <br /> Print Name /1 -.�� — --- <br /> DEPARTMENT USE ONLY <br /> # SITE MAP IM UNIT Ill FILE,ADDRESS: <br /> i <br /> WORK PLAN! DATED: <br /> 1 <br /> 3 Application Accepted By Date Issued - Area <br /> Grout inspection By Date Final Inspection y Date 3 <br /> Destruction Inspection By Dat <br /> COMMENTS 1 CON DiTIDO <br /> ACCOUNTING ONLY: AID# FA <br /> ��mL e'rlti <br /> PE Cpl?!=5 FEE INFO AMOUNT REMITTED CHECK# RE9'D BY 9ATEjPERMIT I SERVICE REQUEST# INVOICE <br /> 3b 11,Z <br /> C-57 — WC--_-WAIVER.— C-57 Letter of Authori ation t s" e rnit Encroachment doc 9/27/00 <br /> EO 30VJ i NOD-13 Hi-AT J EEhE13Sb60� 9�:6T TO��}g�}rZ0 <br />