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0-�-113-200i 01:37PH FPCf,1 TO F.131 <br /> WES PERMIT APPLICATION ARM SITE <br /> FRI I _-- MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> MAY 1 7 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 'i- LTH 304 E.;Weber,Third Floor, Stockton, CA., 95202 <br /> i L r S (209) 468-3449 <br /> NON R FSE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct anator install the work described. This application is made in compliance with San <br /> Joaquin County Development Tine.Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> AzsessoWELLLocatlon 402,oN �EwRa. Crossstreet'STFv�SCW SideK ziv�S2u� Parcex <br /> PROPERTYOwner htLHA& UYAIN A Address_ D C AqISTAWLCity Lob I _Zp 9�Phone Ld 9 I- 836 <br /> V (utx <br /> C-57 Contractor FI SLR AV II ROW-4(�q X5 399 S Mgt'S &.0ity mzip ySl�.Lica�tsJ kbsPnoner: D 3 - �FS6„ <br /> S P Ay,(nta Cir r/lL(I�TE L-c# Phoned S�0 F( - co <br /> Consu)tant/SubContreaorATC. RaOLIA'[43JAGAddress <br /> GIS Coordinates:X <br /> y.-Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPOIL BORING#I VNCH,HAND-AUGER,OTHER') ti n OVER-BORE <br /> -aLSti WELL 4 U PRESSURE GROUT <br /> Other_ Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> II MONITORING n HOLLOW STEM OIA-OF BOREHOLE MULTIPLY!CASINGS?�YEJ Q NO WELL CASING DIA-'— <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: I)STEEL 13PVC [IOTHER: <br /> 1]VAPOR n MUD ROTARY DF;PTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS ❑HOSE <br /> a AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or a STOVE PIPE <br /> U OTHER: CIOTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? (if YES,list SPeciticafions here)! <br /> — <br /> .COMMENTS: <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 /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' antes, Rule and Regulations, and all applicable California State Laws. <br /> TinelCompany. PwiErT GL�L/La(m <br /> Signed x <br /> A�kv(A ALL VAA, !! Date .� I <br /> Print Name DEPARTMENT USE ONLY - <br /> i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Applif C, Data Issued DO Area <br /> Grout Inspection <br /> accepted By I . Cl--bate <br /> Grout Inspection By <br /> Is Final inspection By !—� <br /> Destruction Inspection By a <br /> COMMENTS ICON DITIONS; <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE MFO AMOUNT REMI ITED CHECK 3 REC' BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Zqo T,00 tti, AL 0001 <br /> C-57_ WC_-WAIVER C-57 Letter of Author z io sig permit_Encroachment doc_ 9/27/0 <br />