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WE16d PERM IT-APPLICATION 'RM SITE <br />�. . ' -MITIGATION, <br /> SAN„JOAQUIN COUNTY�PUBLIC~HEALTH SERVICES UNIT A <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NOWREFUNDABLE 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 Develop ent Title,Chapter 9-1115.3_ and the Standards of San_Joaquin County Public Health Services,Environmental Health Division. <br /> ,,�'�� } Assessor'sl45-03-01 <br /> WELL Location rOr'- o �Sto�K b Cross StreetRd 6, Rd '4 City Stockton zip 92503 parcel#. <br /> PROPERTY Owner Port Of Stockton Address <br /> POB 2089 City_ tockton Zip 92501 phone#209_946-0246 <br /> C-57 Contractor Spectrum Address <br /> Wigwam Dr- City Stockton Zip95205Lic#51226 ,hone09r465-8712 ; <br /> nsult <br /> C <br /> i <br /> Geomatrx o �(3 $5.2444 Main St.#21r� Fresno 559-264-2535 y <br /> Consultant/S %S�4kR7NoX City Lic# Phone# <br /> Township 1 N Range 6 E Section n/.a <br /> GIS Coordinates:X Y p n. . <br /> WORK TO BE PERFORMED: <br /> ,V%NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER'). 0 DESTRUCTION(choose type below) <br /> I]SOIL BORING# [)OVER-BORE <br /> X11 WELL# MW — [)PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COIAMENTS: <br /> TYPE OF WELL ' INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X4]MONITORING )THOLLOW STEM DIA-OF BOREHOLE 8r�, MULTIPLE CASINGS?(j YES XUNO WELL CASING DIA: 2" <br /> 0 EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: 0 STEEL Xn PVC [I OTHER: <br /> []VAPOR lZ MUD ROTARY DEPTH OF GROUT SEAL 20-21' r0REMIE TYPE TO BE USED: AUGERS HOSE <br /> 0 AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: []Yes X"No (NOTE: MAXIMUM FREE-FALL. DEPTH IS 30') <br /> [I SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neat cement <br /> [I OTHER: 0 OTHER APPROX.BORING DEPTH 40' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? no (if YES,list specifications here): <br /> 'COMMENTS: Well location and total de th (will not exceed 401 ) will be ,determined from .results <br /> _ <br /> of soil boring investigation. _ <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 <br /> County Ord' nces, R nd Regulations, and all applicable California State Laws. <br /> Signed xr� �+"'�Title/CompanyP(�lCcd����['sJ 1C��Ciw�a� f i <br /> Print Name Date /Z O) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT [V FILE, ADD ESS: a ( �� I <br /> WORK PLAN DATED: GI l { -0 <br /> J <br /> Application Accepted By_�� _ Date Issued `�i j j <br /> —Area-1 `f <br /> Grout Inspection By Date,_ T,`�' Final lrispection By Date <br /> Destruction Inspection By L Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE- <br /> 4 (, i ?_� 4,110 i , n 3 S <br /> C-57 WC, -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doC 9/27/00 <br />