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WELO—RMIT APPLICATION FG0 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 /> STPT%' oi'- Assessor's SeuTl+ OF <br /> WELL Location $oZ Wt=1T w V Y / Cross Street L1'UC oW City ip rl SZo3 Parcel# I Y s-Z&0-01 <br /> PROPERTYOwner C MA''} Address M161=-Ck1A, VZB14LUP'y City �"� ZipgS I Phone#fZo9) 9Fr <br /> Y -3$1f <br /> C-57 Contractor�Olir ORILu 5 Address 3&37- lam LZ. CI'rr-Lcr CityZp95"?YZ Us#O IY90 Phone#(9/6)66- I/69 <br /> Z^Acec <br /> Consultant/Sub Contractor'59t��-V-:-E�n"nE-�-Address'3ot7 KILA&t-c PJ06 City LC --* Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township 1.y Range 6 Ls- Section to <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 'rWWELL# MW-33 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a <br /> 91AONITORING POLLOW STEM DIA.OF BOREHOLE 9// MULTIPLE CASINGS?0 YES YNO WELL CASING DIA: z <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS SCti-yb TYPE OF CASING: D STEEL )PVC D OTHER: <br /> DVAPOR aMUD ROTARY DEPTH OF GROUT SEAL`S/IY0/ TREMIE TYPE TO BE USED: DAUGERS 'f'HOSE <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: )[fYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS:Nc'xT Cep 0— ' <br /> D OTHER: 0 OTHER APPROX.BORING DEPTH zS//Sir 0 BOLTED TRAFFIC BOX or 'STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 'V 0 (if YES,list specifications here): <br /> 'COMMENTS: LOL2LS M W—Zell A� �Mu-3Z ALr rX-eP cd0. s taS'W IF A Cep+M+ 1-5 L�YerL IS F. ee >07VA,1%, l»SF <br /> LJ<Li S. W. 3F 0SI^-,5 Aw A11 ftoPnAH WIHFAnme�- cAsa .x, 'hu k^t[7FF 'INS r-'/ "zeA&*t zz-' '=. <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 /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed —T-"4,k, Title/Company PH7ru 4e-a.-c.4'S7" SLC -'>t'Icssxnu-a.` <br /> Print Name 17HV ^AS 1, PA,(V� Date 3) 17/03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (r1 I pT/ <br /> Application Accepted By ' ' W Date Issued 1q. a Areay // <br /> Grout Inspection% Date Final Inspec ion By Dates[ v3 <br /> Destruction Inspection y Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cerw <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2,10 8 qlI? 03 sR# 33 10 <br /> C-57_ WC=WAIVER_ C-57 Letter of Author) on o sign p rmit_Encroachment doc_ 9/27/00 <br />