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WEL[e _-RMIT APPLICATION FCO I 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 �uZ W�;� t"� `'L Cross Street Lt-uC�<N s�u��-e-,.-i Z� Assessors <br /> C�tY Zip9S 3 Parcel# IYS_zYo_C) <br /> PROPERTY Owner C>Mt-w Or.,4.-�x � r Ld W e <br /> ^`i 5 Address MR. 5: F�dot CitY »ucru-J Zip /Szc.l Phone# lzo9j44/r'x700 <br /> C-57Contractor Co"�'«4 44Lu.5 Address 3y32. Cmezci"i Ls City�p,;nra Zip`/57YZLIC#�t7 Sr`� Phone# (9h) L3$- it&q <br /> Consultant/Sub ContractorSt__Oi "A$7L^"4T)o^ 't Address3�j,7k115`•`e tk/W City ''O' Lic# Phone#�9 -LyCJ <br /> GIS Coordinates:X ,Y ,Township 1 N Range 6 L! Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# I A- '•1 i <br /> ,'8'WELL#Ah W-23., . r-ZY,M w-2�t w.iw-2'7rnr u-31 j 'YI"' ZJ "1' COVER-BORE <br /> 'Other: Grout Specifications: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> "ONITORING %HOLLOW STEM DIA.OF BOREHOLE 9-" MULTIPLE CASINGS?DYES (FNO WELL CASING DIA: 2 n <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -rcw- 40 TYPE OF CASING: 0 STEEL gPVC 0 OTHER: <br /> - <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL s Y oA TREMIE TYPE TO BE USED: 0 AUGERS <br /> t}10SE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: IfYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: N 7m C t>m G <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH V Sir BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?Na (if YES,list specifications here): <br /> 'COMMENTS: W�2�5 M W-Z4 Arm .t+w--2`7 ,S,trr l)A:Wo W��S -,-o moi- !TF q-TkCc u'n R.+ryS C.ny t*C IS Cru couvZ,.ct,•� <br /> o;+E' t..s11u.5 C.;; �i .yLr L�.nO��'R'd USI-moi AA-e Ay A,.i iLo�-hyl wllawrwh r.� U}5� <br /> 'N Sem eft f.�MrecU.u.r, "Ze5-e5 <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 x1 Title/Company/'4�7<�T_ C)eD ;4155 SE_.t Srvltx.v,n�J�.L <br /> Print Name 7R V? ^S Y, P-44,k P+t Date AAAA--AA3 F70033 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted B L&14Q7 _ Date Issued Areal <br /> Grout Inspection 8y Date Final Inspection By Date <br /> Destruction Inspection B Dat ��� <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> cera <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC' B DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z21 . 00 S 8 ` o a sR9 3 Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorfz#org s' n ermit_Encroachment doc_ 9/27/00 <br />