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SITE <br /> WELNPERMIT APPLICATION FU M MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH 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 I YEAR FROM DATE A.ISSUED tion is made in compliance with San <br /> Application is hereby made to San Joaquin,County for a permit to construct and/or install the work described. lnisaPP"ca <br /> Joaquin County Public Health Services,Environmental Health Division. <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Zi Assessor's <br /> tion AOCA Cross Street E��Waf 5-�­City CAnJ4M.— z _Q�j�S Parcel#_— <br /> WELL Loca City 0 LTJ <br /> zip 6-) 262 951 �j5� <br /> 4056tddress-(,-� �-o :11� <br /> PROPERTY Owneraav_ 09- <br /> �3v4f 155TV-10Phone# 2 7� <br /> vCity'4ncw Y-�7 <br /> C-57 Contra ze%a Address <br /> ctor <br /> ic#-Y�O ?Phoneo <br /> ity 2�6�700 <br /> Consultant I Sub Contractorvokli !A vt,,V�Nddress <br /> Section <br /> GIs Coordinates:X� Township Range <br /> an <br /> WORK TO BE PERFORMED: )OTHER- d�-75STRUCTION(choose type below) <br /> *EW WELL/BORING(CP 1.GEOPROBE,HYDROPUNCH,HAND-AUGER a OVER-BORE <br /> (I SOIL BORING# JAN 16 2001 a PRESSURE GROUT <br /> XWELL#jj�� <br /> *Other: Grout Specifications: - <br /> COMMENTS: EL -PAITH-S <br /> iV!Cr <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'f <br /> )VAONITORING -WiOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?11 YES %-40 WELL CASING DIA--CRL <br /> a EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS, \ XPVC a OTHER-._ <br /> TYPE OF CASING: U STEEL <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL—(2 � 0 .TREMIE TYPE TO BE USED: 'AUGERS a HOSE <br /> a AIR SPARGE (I PUSH POINT GROUT SEAL PUMPED: 11 Yes UNO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> - I <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS:_ <br /> �W60LTED TRAFFIC BOX or a STOVE PIPE <br /> [I OTHER: (I OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED?:2X7(if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> S <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOUR 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 Onances, Rules Regulations, and all applicable California State Laws. A <br /> Signed x—�oll X2A� Title/Company <br /> Print Name R c I C-L V-x Data <br /> • DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��r D <br /> I law <br /> WORK PLAN DATED: 'a!220-- <br /> 1 Area <br /> Application Accepted By Date Issued -I I I :�- — <br /> Grout Inspection 8 1t NA Date By OL, <br /> >101 _Final Inspection Date q-c' <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS- <br /> 7 S <br /> 4M <br /> ACCOUNTING ONLY: AID# <br /> FArg <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 35-01 <br /> SR# 00ASO <br /> C-57— WC -WAIVER C-57 Letter of Authorization to sign permit—Encroachment doc—. 9/27/00 <br />