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WEP—L PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> REEVE, ENVIRONMEN L HEALTH DIVISIONA �(PH 2�HD) UNIT IV <br /> 3 d <br /> 7 2001 (209) 468-3449 „�,�� U�r• <br /> NOV LUo`''�� 5600 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is h reby,made to San Joaquip County far a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br /> Develop€i�(IWIAUp)dhaptdr90-\115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> �ifh7�i0�+'Pelcc <br /> obf o Assessor's <br /> WELL Loc' on Led�y- y� 1�_Cross Sttr]reeeLt[7 city$Z'oc. Crad Zip 52U parcel# /O - -207-05/ <br /> PROPERTY Owner <br /> // /LOy1Q Il ry Address�,�[/rr PG g,�.0 Ave CityS-UCkturt Zip�p7Phone# 7O� 15,2 '62�-1 <br /> C.57Contractor G FtillY) Address 950 hIvGJP Rd Ciry 3r'tl ip9y5s9Lic#6byd7Phone# 5 13-6804 <br /> Consultant/Sub Contractor_ --v,kvmwertu l Ab,lyddress_1060 A M 11yity ke—h Lic#6031 Phone# A ,'� - Sa� <br /> GIS Coordinates:X ,Y ,Township Range-_Section <br /> WORK TO BE PERFORM <br /> ANEW WELL/BORING(!9 GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> OSOILSORING#_CPr Un DOVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> COMMENTS: <br /> `Other. �f 1 Grout Specifications: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIE CATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 4 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> g VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes 0(/No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OSOILBORING 0HAND AUGER GROUT SPECIFICATIONS: <br /> c <br /> 0 OTHER: R OTHER APPROX.BORING DEPTH 15D' RA <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Regulations,and all applicable California State Laws. <br /> Signed xLH itle/Company <br /> Print Name_ r��21t t!l /'/COfh vvl Date �( I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5(006 <br /> WORK PLAN DATED: IO 0/ <br /> Application Accepted By /��'3 �� o(9•.�l <br /> --* <br /> Date Issuetl / Area <br /> Grout Inspection By Date Final Inspection By a •�p�DestructionInspectionBy Date u _ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REM,11TTTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a ' �Z i�-� R# O aA <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br />