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WEL*ERMIT APPLICATION ROM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <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 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 /> WELL location S Z� W ' WLyl L'ti A'vC- Ll A0�,,,/ n Assessors <br /> � oN 0.� Cross Street N' City � �N"-i qs,, <br /> wAn'F;'� Zip 3 Parcel# 13> -Zbo !� <br /> PROPERTY Owner T'w-0%%& ofi+c Address 'OOb-0--A"re- Ciry 5 A) ZIp!S—b2 Phone#(Zn9) clo-WIJ <br /> C-57 Contractor CA 5CAc`0- ll t4u.WS 0^45L `�• cry Address 3837- 0IZ�ct+o <br /> c�o.�.,zip9S')y>tic#717Siol=honen(9/6)L3&'-ff159 <br /> Consultant/Sub Contractor See OA— of (9/sJ£rbf-D <br /> Address3 7 ICllfrorGt� Cityc:.xc#✓A- LIcN Phone# y00 <br /> GIS Coordinates:X ,Y ,Township � Ran e S <br /> 9 6 �' Section I C) <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,G Q[iQ?HYDROPUNCH,�HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> ',01 SOIL BORING# §P-1/4Y.-2- ()P-; <br /> Y,WELL#Mto -47/mL-V.F- Mw-Y Mw-Sb�Atw—Sf OOVER-BORE <br /> *Other: 3 AOOWfow&j toeLL. w�Ml ­5—Grout Specifications: 11 PRESSURE GROUT <br /> COMMENTS: 1 iccxnn.., (,- (,P-f,(�0-2 h�2 4rtrrl �a Cx h�A cv Actl R¢y�crs 5� �,3T A�MLS AS <br /> i'nw-Y7-Sr <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS We-Li-S <br /> - MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE_MULTIPLE CASINGS?BYES';8 NO WELL CASING DIA:_ <br /> ()EXTRACTION %AIR HAMMER/DRIVEN CASING THICKNESS 2-" TYPE OF CASING: U STEEL ,X PVC BOTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL­Yf TREMIE TYPE TO BE USED: 0 AUGERS '$HOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Ryes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING UHAND AUGER GROUT SPECIFICATIONS:_!✓Enr Ct>mg, 7- <br /> 0 <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH S'o )OOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ,4Ja (if YES,list specifications here): <br /> *COMMENTS: lVttl$S�''�-e.+c-+� i- vS-Sa' <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 /> 1 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 Tide/Company P"31acr L)e'0�06r ST �Slrc a.-C <br /> Pdnt Name —FIR-0 /I y/S <br /> oS- <br /> DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: /// J ,'/ <br /> Application Accepted By [-"l,' r 1 C'a47 Date Issued- Z I a 1 Area <br /> Grout Inspection By DateFinal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> oerw <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK* REC'D BY DATE PERMR/SERVICE REQUEST# INVOICE <br /> 4(1L 9 <br /> 15-57 WC -WAIVED_ C-57 Leffler of Authorizat on to sign permit_Encroachment doc_ 9/27/00 <br />