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0 0 ORIGINAL <br /> YELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> N A <br /> IN COUNTY PUBLIC HEALTH SERVICES JOAQUUNIT A <br /> �7 �t�,•Ill, NVIRONMENTALHEALTHDIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 �� 0 aJ <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 /> Assesso 's <br /> Z3S6S- S, SrtAfr1 e- Rd Cross Street CiryR"re:ba✓ k zip �153(LParcel# q'b70-G[� <br /> WELL Location ,p n <br /> OwOe <br /> PROPERTY UGIT 1 �A*F fA Address �3nnSES S. SG1(%+a qP pkiTy 1c,yer-6,\V Zip q"s3c&7 Phone# (ZcS�83R-7S%� /' <br /> �Jb-W rjrr'ill In P0, &>e 4 � 6 Ci �-s12�A Zi q�4[ Lic#12-c+]oN Phone# 9Io 177--7(170 <br /> C-57 Contractor 4 Address N P <br /> Ry���o <br /> Consultant/Sub Contractor SL-ccR Sn•�+�+to^4( Address 3'1T Kul 1_404q Lic#G[OZ Phone# <br /> GIS Coordinates:X ,Y ,Township 3 'S`;ut h Range et Li1S Section 2 <br /> WORK TO BE PERFORMED: <br /> VIEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') []DESTRUCTION( hoose type <br /> below) <br /> []SOIL BORiNr-" <br /> WELL#_5--7-[t5-22� 5-23. []PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING '%6OLLOW STEM DIA.OF BOREHOLE- MULTIPLE CASINGS?[]YES XNO WELL CASING DIA: �.2-S_r <br /> 0 EXTRACTION []AIR HAMMERIDRIVEN CASING THICKNESS r TYPE OF CASING: []STEEL XPVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 3 I TREMIE TYPE TO BE USED: YAUGERS ,HOSE <br /> `LSPARGE []PUSH POINT GROUT SEAL PUMPED: )Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> []OTHER:—H OTHER APPROX.BORING DEPTH XBOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N o (if YES,list specifications here): <br /> 'COMMENTS: <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, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Companl S s—c-clr-� 'n �n A�'1 O hQ Z:V"C' <br /> pp Date [ OZ <br /> Print Name P plan C;aa^e� Si-a�'� G eo loy iS-� <br /> DEPARTMENT USE ONLY Q <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ZJS�oq S <br /> WORK PLAN DATED: MR 2 �� COR.tilo vL <br /> Application Accepted By Date Issued �' Area i <br /> Grout Inspection By <br /> Date Final Inspection By _ ate �d. '0Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: ' <br /> ACCOUNTING ONLY: AID# �nrx <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST If INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_ - 9/27/00 <br />