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4 <br /> WEL 'ERIVIiT APPLICATION �RM SITE <br /> _ . .-MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEAL'TH'SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor; Stockton, CA., 95202 <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 andfor install the work described. This applic�.tion is made in compliance with San <br /> Joaquin County evelop Title,Ch pt 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. j <br /> J� Assessor3145-03-01 <br /> WELL Location <br /> %Ort o�Stot: b Cross Street Rd. 6, Rd. Stockton Z;p 9: 03 Parcel# . <br /> Stockton 9§_Xl 209-946-0246 <br /> PROPERTY Owner F <br /> Port of Stockton Address POB 2089 City Zip -- Phone# <br /> C-57 Contractor Flsoh Address 399 Sheri'S Pl. c;tyValley Sg;gs. tic# $65Phones 09-_772--3570 <br /> Ste. 215 ^3 <br /> Consultant l;� M Geomatrix Consultss2444 Main St. City___Hre, n jc# Phone# .559-264-2535 <br /> Y Township 1 N Range 6 E' Section n/a <br /> GIS Coordinates:X', . <br /> WORK TO BE PERFORMED: " <br /> ANEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) B DESTRUCTION(choose type below) <br /> JkSOIL BORING# 40 OVER-BORE �{o <br /> F1 WELL# Neat cement grout f�0M t]OtC01 U T <br /> 'Other: 4 direct push Soil orin s Grout Specifications: <br /> COiv1MENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 1]NO WELL CASING DIA: <br /> {]EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL n PVC []OTHER: <br /> p VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREM1E TYPE TO BE'USED: []AUGERS []HOSE <br /> Q AIR SPARGE X0 PUSH POINT GROUT SEAL PUMPED: p Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AgSOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH 11 BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS. 2" diameter direct push borings backfilled with cement/grout when comple e <br /> cl <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 Ordinances, Runes Regulations, and all applicable California State Laws. / <br /> ar ,SC�{le1Com an G <br /> Signed x P Y Aar-e <br /> —��U k <br /> Print Nam Date <br /> DEPARTMENT USEONLY <br /> SITE MAP IN UNIT IV FILE, ADDRE f2A ,3 -4- 14 f G <br /> WORK PLAN DATED: S <br /> Application Accepted By Date Issued 1. ` lo t Area <br /> Grout Inspection By Date a Final Inspection By .Date <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3SaI I ` I Eiji I ;1 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> i <br />