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NOU-30-2000 15:08 GEOMRTRIX FRESNO 559 264 7431 P.03iO3 <br /> ELL PERMIT AFrLICATION FORM SrTF- <br /> MITIGATION <br /> i�� N dOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIIV <br /> ENVIRON MENTAL HEALTH DIVISION (PHS-EHD) UNIT <br /> 304 E- Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 463-3449 <br /> NON REyu NDABLE PERMIT EXPIR,--,1 YEAR FROM DATE IS3UED <br /> Appiication is hereby made to San Joaquin County for a permit to wnstruct and/or install the work desalhed. This applloabdn is made In mmpliance with San <br /> Joaquin County Development Title,Chapter Fri 11 and the Standards of San Joaquin County Puhlic Health Services,EnvIronmental Health Division. <br /> AssesWELLLocation Cherry Road Cross Streetf- HwV 12 City Victor, CA o95253 Patel# n/a <br /> PROPERrr Owner San Joaquin Count_�gddrass 1810 E. Hazelton AvElhj Stockton zp95205 Phone# 209-468-305; <br /> C57 Cnntrackfr l�II N�LL1�Add eSs <br /> a,s�2 LI..o�'�' City —Zap Ill �3�Lo 5"'? Phonei f� 6 021 <br /> Consultants, inc. Suite 215Fresno L�A60145Cdnex 559-264-253` <br /> Consultant I Sub Conm=r Geomatrlx Address Main S eet Cry <br /> G15 Coordlnatas:X - - <br /> y ,Township 3001:th Range ?East Sect= 4 <br /> WORKTO BE PER O� pEy–IRUCTION(OVEFs type below} <br /> RJEW WELL I BORING(OFT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER? 0 OVER-BORE <br /> pO SOIL BORING# D PRESSURE GROUT <br /> 30w;-LL tt C244 <br /> ,OtherGraut Speafioations: <br /> COMM, NTS ell located 2x000 ' north of H 12 on west sloe cf Cherry Rd. ng t-o -way <br /> TYPE OF WELL INSTALLAOON=E CONSTRUCTION 22ECIFICATI0115 <br /> rMCNITORING )J10LLOW STEM DIA.OF BOREHOLE 10" MULTIPLE CASINGS?DYES SNO WELL CASING DIA: 4" <br /> 0 EXTRACTION 0 AIR HAMMEMRIVEN CASING 7HICKNESS Sth-- 40 TYPE OF CASING: D STEEL 7DPVC O OTHER: <br /> O VAPORQ MUD ROTARY DEPTH OF GROUT SEAL 55—�_TREMIE TYPE TO SE USED: &kUGERS O HOSE <br /> a AIR SPARGE DPUSH POINT GROUT SEAL PUMPED: WYes allo (NOTE: MAXIMUM FREE-FALL DEPTH 15 30') <br /> O SOIL BORING 0 RANO AUGER GROUT <br /> SPECIFICATIONS: Bentonite/cement 31 lrry <br /> D OTHER: D OTHER APPROX.BORING DEPTH 50 r IFBOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONOUCCOR CASING PROPOSED? NO (it YES,Vs specifications here$ <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CAI LTHE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REt]UIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the Work will be done in accordance with San Joaquin <br /> County Ordii}nkancnces,Ru//le�s and Regulations, and all applicable Californian State Laws. <br /> r�LJ Gr-'-' �dp <- TltlelCompanY,f''-'�'ro✓ �,c�wyD�irs� / /nm�raG <br /> Signed x /01 �,/ - <br /> PrintName /lrx ZI r1 f3ectA Date Z <br /> I]EPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: ■ <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued I z,�11 Lo C PFea <br /> Grout lnspeotion By_'_ Da- -c, o Final Inspection By_ ( �-JA <br /> ,..r.... Dat z �' <br /> 095trU6tion Inspection By Date <br /> COMMENTS(CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> pE CODES FEE INFO AMOUNT REMITTED C71ECX# PEC'D BY DATE <br /> PFRmfT/SERVICEREOUEST# INVOICE <br /> a`loI %-00 Ozs 13 I lyl� OOa`i �S 3�j <br /> C-57_ WC; WATVER.__y_ C-57 Lettsr os Authorization to sign permit_Encroachment dac_ 9/27/C <br /> TOTAL P.03 <br />