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(✓MIR-82-2001 14:38 <br /> PORT OF STOCKTON �U' 1`0`' (G~~ vV <br /> WEI PERMIT APPLICATION RM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL���HStloclSION kton, CA.9�0) <br /> 304 E. Weber, Thl 468-3449 <br /> (2o9) <br /> ON.REFUNDABLE✓PER}lln'FJCPIRES 1 YEAR FROM DOTE ISSUED <br /> for a pem,iE b oonstruG and/or install the voAr dtLsa'IDed. This apvllcation is made(n Wmvliance w�tn Sen <br /> Application i6 h®rely nada W San 1ChaDk Courny' ASSeSsorS <br /> .loaquin County Development Tate.Gheplcr 9-1115.3 and the S!`indarcL of San Joaquin County Public Health Services.EnvEronmentat HeaEtn Oivis�on. <br /> wELLLOcationRoberts Island-House Road cross street <br /> Holt Road city Stockton zIp95203 ParcelSl1-23-01 <br /> 2201 W Washington C►ty Stockton Zip95203 Pnoneu209-946-024 <br /> PROPERTY Owners tockton Port Distric4dtu�s P easant Phonett91 - 91-2999 <br /> Zp95668 L�dt4 8 �6 �- <br /> C-67 Contractor All Terrain xnl nACaress F 0 B^v phono�k 559–�hL�2535 <br /> .�/// tit.•i n S t awl_5 G�N�r Pte.G–,n� –LicJit <br /> Consultant"Geomatrix Consul tau <br /> 121.3794WY 37.9670N Township <br /> Fangs Sea;on <br /> GIS Coordinates:X`_ ,WORK TO g—P�3;CORIM_ED:_ 0 DESTRUCTION(moose type below) <br /> U ORK WELL/BORING(CPT,GEOPR06E,HYDROPUNCH.HAND-AUGER 07HF ) 4 0 OVER-BORE <br /> Q SOIL BORING IF Q PRESSURE GROUT <br /> p WELL tt Grout Sperif=t on <br /> -Other- Hollow S em A <br /> COMMENTS: <br /> TYPE� 1�57pmt.A-T10�11Y r: CONSfRUCT10N 5PEC1FIC1t71�u MULTIPLE:CASINGS II S x`0 WELL CASING DIA:9—i n. <br /> / pOCNITORING 6,HoLLOW STEM DIA,OF 8OREhOL..j�–i�- STEEL <br /> DVC Q OTHER: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS SCh$40 t. TYPE 7REM OF tNTYPE TO E USED: AUGERS 0 HOSE <br /> p vAPOR MUD ROTARY DEPTH OF GROUT SERI_,,,_ <br /> D AIR SPARGE p PUSH OTARPOINT GROUT SEAL PUMPED: 0 es *No (NOTE: MAxIMUM FREE-FALL DEPTH IS 3d) <br /> entonite <br /> p SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> APPROX.BORING DEPTH f t. %4 BOLTED TRAFFIC 60X or j]STOVE PIPE <br /> 0 OTHER: 13 OTHER NO (if YES,1i�soecifieations here);, <br /> CONDUCTOR CASING PROPOSED? <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE� ENCROACHMENT <br /> FoR��.ou� IPERMITS.�oNs. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE <br /> I hereby certify t 1 hav this application and that the work will be done in accordance with San Joaquin <br /> County Or and gulations,and all applicable Cal'ifomia State Law . <br /> �� TtlelC,ompan - � <br /> si9r+ed x � _p <br /> ��" bete 3- <br /> PrintName DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: l r �" <br /> WORK PLAN DATED: <br /> C12- <br /> Date Issued 7 i Area <br /> Application AccOpted By Dale d <br /> Grout Inseection ey Dare fSnal InroeC.ion By <br /> Destruction tnsoacden By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY; AID# <br /> PE CODES FEE INFO AMIOUNT REMITTED CHECKS RECD BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> ign permit Encroachment doc 9f27/( <br /> C-57 WC -WAIVER C-57 Letter of Authorization to s <br />