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WELL'ERMIT APPLICATION FRM SITE <br /> C,11 :. <br /> Iq MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT N <br /> .IAN 3 0 20QZ ENVIRONMENTAL HEALTH DI ISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stc ckton, CA., 95202 COPY <br /> EfVViRO(1. iE;s ,: ; (209) 468- <br /> PERMfT/oEF, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance-Mth San <br /> Joaquin County DevelopmentTM6,Chapter 9-1115.3 and-the Standards of San Joaquin unty Public Health Services,Environmental Health Division. <br /> Assessor's <br /> r �D S%cC�!7l rnip ^Parcel# /yf-io�-603 <br /> WELL Location L�3-� '�Y�+.t S �F Cross Street S. itY 9 I <br /> PROPERTY Own" Address�� 1C . City r7ip _Phone# �w13� <br /> .. <br /> Ep O <br /> iLf <br /> C-SlContractor��— LU9(r Address.53cD �_ZJ " S <br /> Consultant 1 Sub Contractor Aly afr�Fm �;.qm hz7A mdress Ill. 500111) City��Lic# <br /> 4)Z77 Phone# <br /> GIS Coordinates:X ,Y ,Township Range SeCtian <br /> I <br /> PERFORMED: <br /> /BORING(CPT.GECPRO@E,HYDROPUNCH,HAND-AUGER,OTHER ) Q DESTRUCTION(choose type below} <br /> SOIL BORING# p OVER-SORE <br /> WELL# - PRESSURE GROUT <br /> .0ther Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEC[FICA ONS <br /> Y—MONITORING HOLLOW STEIN DIA.OF BOREHOLE f MULTIPLE CASINGS?a YES f10 WELL CASING DIA: <br /> 0 EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS b TYPE OF CASING: Q STEEL )PVC BOTHER-- <br /> VAPOR <br /> OTHER:VAPOR (]MUD ROTARY DEPTH OF GROUT SEAL--,'ES TREMIE TYPE TO BE USED: OUGERS Q HOSE <br /> AIR SPARGE []PUSH POINT GROUT SEAL.PUMPED: Zys a No (NOTE: MAXIMUM��FREE-FALL DEPTH IS 30')' <br /> [I SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: ' a T 1 ff <br /> O7L{E� OTHE=R APPROX.BORING DEPTH it ,10OLTED TRAFFIC SOX or a STOVE PIPE <br /> CONDUCTOR CASING PROP SED:]? (if YES,list specifications here): <br /> 'COMMENTS: /G a f! �vZir E!r !.✓ [ c� gC) <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS INA DVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin <br /> County ances Rule an Regulations, and all applicable Ca ifornia State Laws. <br /> Signed x 1 � - TitielCom y i ls�L <br /> Print Name k Z>ti l Gate �( <br /> DEPARTMENT U E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' o a <br /> Application Accepted By <br /> rDate Issued 7 d Area <br /> Grout inspection By Date O Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS J CONDITIONS: <br /> ACCOUNTING ONLY: AID# a <br /> PECOVES FEE INFO AMOUNT REMITTED CHECKS REC"D BYIDATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 9/ 7/00 <br /> C-57 WC -WAIVER C-57.Letter of Authorization # sign permit Encroachment doc <br />