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WI. PERMIT APPLICATION F M <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SITE <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) MITIGATION <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> Well Location 2yvc E. M 1v�R�vE Cross Street " D" Sit«e-T City ,-r-o4-r-4 Zip Ty2c Parcel# <br /> PROPERTY Owner`/UAA r-t. ,> "�'�"' Address City zip Phone# <br /> C-57 Contractor V 1 g'0 '-'x Address ,2110 i4t- City 11&Klo�qZip 9 q 5}} Lic# -+05`t d 3 Phone#5/0 •'-ipS--4(,W- <br /> Consultant/Sub Contractor& Its CWAddress 11d &%'yuellkyry• City tc1u0A- Zip9,0}s,e3 Lic# Phone#92--LYM-`1ull <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) [] DESTRUCTION (choose type below) <br /> /, \\ SOIL BORING # 513 i - 154- [] OVER-BORE <br /> []WELL# [] PRESSURE GROUT <br /> *Other: GI�EiJ �t�406r +'F V401(A wiU-­ -ro GROUT SPECIFICATION <br /> �1z''u W'9 w�iicrL �- F�Dr6 W 1� Sti,ul PSS c��c-7�.t� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [] MONITORING [] HOLLOW STEM DIA. OF BOREHOLE_ MULTIPLE CASINGS? [] YES [] NO WELL DIA: <br /> [] EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL [] PVC [] OTHER: <br /> [] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br /> [] AIR SPARGE PUSH POINT GROUT SEAL PUMPED: [] YES [] NO (NOTE: MAXIMUM FREE-FALL DETPH IS 301 <br /> ROIL BORING [] HAND AUGER GROUT SPECIFICATION <br /> [] OTHER: [] OTHER APRROX. BORING DEPTH - �' / [] BOLTED TRAFFIC BOX or[] STOVE PIPE <br /> COMMENTS: jZ�4r-IfkF 1 511- Fr-R1ulrc/wetA� 5;k1.A9yN1• Y�1NTs. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin <br /> County. <br /> * CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> i 2�r C L-ii(? <br /> Signed x r � 1 1 L Title/Company (1 �I lavu�c3 2 �� L, <br /> Print Name t S�1L� w Date q a5 --)DD 3 <br /> SITE MAP IN UNIT IV FILE ADDRESS / WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 7 Date Issued Area <br /> Grout Inspection By Date Final Inspection by Date <br /> Destruction Inspection By Date <br /> COMMENTS/ CONDITIONS: -ton-, A- CA 114-1<< <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO REMITTED OUNT CHEECK# RECD BY DATE PERMIT <br /> RMIT/SERVICE REQUET INVOICE <br /> Dl "C �t - 0� SR#�G bS <br /> C-57 WC/WAIVER—C-57 Letter of Authorization to sign permit Encroachment doc 7/17/00 <br />