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thy46B3433 <br /> FIFTH FLOOR <br /> PAGE 03 <br /> 1NELL PERM1T APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUN ly PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 98202 <br /> (209) 468-3449 <br /> AppliGaMen is hereoy made b San Joaquin,NON-IEPUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOaquin C•;uoty Cevelcpnent Tile,Chactar¢1113,3 a, In <br /> 3: cd n4Juct anO;onnataf the worx aesaibe-+, This application is made in cempiiance with San <br /> and etq an3rds of San xaqu,County Pubilc Fiaallh Services,Env'mnmental Health Oiulsion. <br /> WELL Locatlan I�7`I S IV�ya1 tRal. Croso Street LQ4,,. r Assessors <br /> City tStud+a^ Z,Ip 9571 Parceirt <br /> PROPERTY Gwner fFQl+.f�-U t,[�a'FV( <br /> -...�_,AdCress(S6dy �{�.t+v.9�,1 City ESWIen Zp yS7L4 PhoneMZ01 <br /> C-57 Cantractnr ��V�utq J'q� Address Pb aw c/t97(ta P <br /> CityKtA�Uh Cp9YC'H UCu3iw�4 Phone# _ftil' 3'}V—It0'3Q <br /> Consultant/Sub Cont^aotor ft-Z. Ac�<t�j gddress�113'I.Jcr++l�ly X63 <br /> GIS Coordinates:XY <br /> LJC# PhoneK t b 1 T}9-t Lt! <br /> 7w+nshiP Range Section <br /> WORK TO BE PERFORMED: <br /> $'lVEW WELL/BORING(CPT.GEOPROEE,HYDROPUNCH,HAND-AUGER.OTHER-) <br /> 0 SCIL BORING# Q DESTRUCTION(choose;ype below) <br /> *Other 9OVER-50RE <br /> COMMENTS: Grout Specincaaons: 0 PRESSURE GROUT <br /> TY"-0F WELL INSTAL— IATiON TYPE CONSTRUCTION SPECIFICATION <br /> 0 MONITORING )RrROLLOW STEM DIA,OF BOREHOLE <br /> 0 EXrRACTICN 0 AIR HAMMERIOP,IVEN CASING-41CKNESSSckVZri �MiJLTIP_c CASING57 11 VES ,'ANO WELL CASING DIA: _ <br /> PE OF CASING: 0 STEEL VC 0 OTHER: <br /> VAPOR C MUD ROTARY DEPTH OF GROUT SEAL Y}' <br /> 0 AIR SPARGE PUSH POINT TREMIE TYFE TC RE I:SED: Q AUGERS b;HCSE <br /> GROUT SEAL PUMPED. p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:_ Lt.1✓ t <br /> 11OTHE^,: I �yQ �04ugvn I� <br /> OTHER APPROJ(.BORING DEPTH (y0 <br /> '6L"ED TRAFFIC BOX or 2 STOVE?fFE <br /> CONDUCTOR CASINO PROPOSED? `J <br /> 'COMMENTS: (if YES,Ilse:pecileations here): <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 apPllcatien and that the work will be done in accordance with San Joaquin <br /> County Ordinance , Rules,and Regulations, and all applicable California State Laws. / p 1" <br /> Signed 'DA � ') ��....,�Y✓�J�. (( • Ttle7Company sk'k'k f IP '11 A%ovtr ` �,�"C /i fJ�<Lry <br /> Print Name pt`- /-'-t l`" Date_ l Z'11`�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Grout C ��Date Issued If 2 <br /> Inspection BY Uate ^ Ama <br /> Cesbuclion Ins Final Inspection By Date <br /> Inspection By Dale <br /> COMMENTS 7 CONDITIONS: <br /> JACCOJNTINjGON�Y; AI D6INFO AMOVNT REMITTED CHECK <br /> EC'0 BY DATE I PERMIT I SERVICE REQVESp"X INVOICE <br /> . U i. I <br /> C-57_ WC=WAIVE_ C-57 Letter of Autho i j o sign permit_Encroachment Bac 9/27/CC <br />