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WELL"T(ERMIT APPLICATION FOAM SiTE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FILL <br /> (209) 468-3449 <br /> UUPY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 Tiitle,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> ccCzCk � AssessoLr1's <br /> C06CkLiyNELL Location Cross Street Parcel# <br /> tt J�0.b' ty�;�t ipe� "L( Phone#_ I t D,- <br /> PROPERTY Owner Address ��t•':S Ci Zi <br /> C-57 Contractor _ � Address l ���, Ci Zi�'t- )Lic# Phone# ZT L. <br /> Consultan Sub Contractor_Q 'f�?c&'_Tc 4,,YAoddress- \0 I l c;j <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> «NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) IJ DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> WELL# I-} o PRESSURE GROUT <br /> "Other: o G \� +�� L o Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING p HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES ONO WELL CASING DIA: <br /> U EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: O STEEL ()PVC. ❑OTHER: <br /> Q VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. Q AUGERS II HOSE <br /> p AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1)SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: 0 OTHER APPROX.BORING DEPTH . 1]BOLTED TRAFFIC BOX or (I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS'-- ` \ `,';'--\(_V o <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordies R lesrld:Regulations,and all applicable California State Laws. <br /> Signed x — TltielCompany A Y•1 <br /> Print Name ��Y`U�f�. ,`v�6�C, ,� Date L4 �— <br /> DEPARTMENT USE ONLY <br /> SiTE MAP IN UNIT IV FILE,ADDRESS, 2-9G'57 <br /> WORK PLAN DATED: /D <br /> Application Accepted By, f:, Date Issued � � Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br /> EO 39Vc! N00-3 H13I3 EEbE89b6aZ 9S ET T06Z/8Z/Z0 <br />