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.lNLS � V'`ui 'I�l' WELLORMIT APPLICATION FO SITE <br /> 2004 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> MAY 7 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ENVIRONMENTVEEL H 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 /> SovfH 4+C!sr c4— <br /> WELL <br /> rWELL Location $0 7-W-W eNL L A.uS Cross Street Lv^`yc�"-^) -� 95Zu Assessor's <br /> City Zip 3 Parcel# tYS—Z70-)S <br /> PROPERTY Owner STbCtro.y rL11A Address 72- L- A't <br /> City ���+� Zipy5Za2Phone#fZa9)93>_�)� <br /> C-57 Contractor Address_ City Zip Lic# Phone# <br /> Consultant/Sub Contractor Sia—L"4_ Address 3017 k-tlyeoef•f�oJ Ciy N Lic# Phone#69/6,)861•-0V o3 <br /> GIS Coordinates:X ,Y—, ('0 Range 6L1 Section lO <br /> WORK TO BE PERFORMED, <br /> �NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> '$WELL# Mto-44rM w—Y� OPRESSURE GROUT <br /> 'Other. I Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r MONITORING )ff HOLLOW STEM DIA.OF BOREHOLES '� MULTIPLE CASINGS?0 YES Q'NO WELL CASING DIA: Z 7r <br /> ]EXTRACTION firAIR HAMMER/DRIVEN CASING THICKNESS'�4 to Yo TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL•3'�yd t TREMIE TYPE TO BE USED: []AUGERS $HOSE <br /> ,]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: $Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ;vu prV C e m .� <br /> ]OTHER: n OTHER APPROX.BORING DEPTHZSrI S� 0 BOLTED TRAFFIC BOX orSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A-'u (If YES,list specificalions here): <br /> 'COMMENTS: ZS' �k o.✓= t3C'rp aa-_. " Sb ' <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 /> hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> ,ignedx I " Tine/Company <br /> Ant Narne `/• PAY[-e aur Date 4/n I S��,a Y <br /> DEPARTMENT USE ONLY <br /> ;ITE MAP IN UNIT IV FILE, ADDRESS: <br /> /ORK PLAN DATED' r, �f�� <br /> oplicetion Accepted By �� Date Issued A /" K/U <br /> Area <br /> rout Inspection By_4 D e Final Inspection By Date <br /> 38truction Inspection By Date <br /> WMENTS/CONDITIONS: <br /> %CCOUNTING ONLY: AID# <br /> renx <br /> 'ECODES FEEINFO AMOUNTREMrrTED CHECK# RECDY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ��I.00 SRO 3'Z <br /> -57_ WC=WAIVER_ C-57 Letter of Autho zatiorrt sign permit_Encroachment doc_ 9/27/00 <br /> ti <br />