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cC,�Cc.oz � s <br /> FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Lam"' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 00 <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 Development Title,Chapter 9-1115.3 and the Standards of Sari Joaquin County Public Health Services,Environmental Health Division, <br /> Assessor's <br /> HELL Location <br /> ZYl"%aih Sir Cross Street OS�r«;�� CRY \o�r�cc� __Zipo1$331• Parcel# <br /> � <br /> CitymCip�533LPhone# -23 <br /> PROPERTYOwneddress 2'7-- � <br /> C-57ContractorV Address gHiCityZ7ip%VyN Lc#'XO1°1 Phone#UI\'1-1�l <br /> � 10� <br /> Consul t f bub 6erttractorG �off,cam.T+c�+r:csAddress ��t Tl'` S t Cityrm Lic# Phone# <br /> GIS Coordinates:X ,y_,TownshipRange Section <br /> WORK TO BE PERFORMED: <br /> ED: DESTRUCTION(choose type below) <br /> U NEW WELL/BORING(CRT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 1�OVER-BORE <br /> U SOIL BORING## U PRESSURE GROUT <br /> � <br /> WELL# E.W a-- . <br /> "Other: <br /> Grout Specifications: <br /> COMMENTS: <br /> TYPE-OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING f HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES U NO WELL CASING DIA: <br /> EXTRACTION AIR HAMMERORIVEN CASING THICKNESS TYPE OF CASING: O STEEL U PVC. p OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. U AUGERS p HOSE <br /> AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: 0 Yes U No (NOTE., MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING {]HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH D <br /> c ACONDUCTOR CASING PROPOSED? �if YES,list specifications here): <br /> "COMMENTS: <br /> SA_. S w p "�"<1- LI—" \" �' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FORALL 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 /> Signed x � � `� _ Title/Company <br /> Yeo rn cj�pr(�J�`� Date 3 0 <br /> PrincName_ U`� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: AJ. ' ` • T !� <br /> ;7C <br /> WORK PLAN DATED: � � �IOGv' <br /> Application Accepted By Date Issued Area U D <br /> Grout Inspection By Date f7 Final Inspection B Date f 2� <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � <br /> C-57 WC -WAIVE{2_ C-57 Letter of Authorization to sign per Encroachment do 9/27/00 <br /> 60 3E)VJ 60011 H1.9I3 EEbE89b6071 99:ET 100Z/8Z/Z0 <br />