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WELD :RMIT APPLICATION He 1 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 /> Assessor's <br /> WELL Location �O( 1�K1' `''G-Sc+� A"<- Cross Street Lt'"r""`u CityS�-�Ta"'1 Zipr{SZ S Parcel# <br /> 148-Z-9 C-C <br /> PROPERTYOwner SToc.r-7%0U rLCPN Address3ts-A ',eZQ�oZ�city S - C`� Zip g57-Z-Phone# (Zoq�`13�-Y`slf <br /> C-57Contractory`Oe Od.LL1N5 Address3S3Z C'hkEL_C`k�,f Ciry c: n Zip`/�yLLic#71y5ADPhone# (976)63g- 1169 <br /> Consultant/SubContractor.S@L�'Lr"T "'"`"^�Address3ot7KIL5 /d� Cityt � `�* Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township I A.) Range 60 Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> �W ELL MW-'14 A-1 �+�+-3S []PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM DIA.OF BOREHOLE r' MULTIPLE CASINGS?0 YES )fNO WELL CASING DIA: z // <br /> []EXTRACTION O AIR HAMMER/DRIVEN CASING THICKNESS SC`,- y 0 TYPE OF CASING: []STEEL N PVC O OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL S/ I v0/ TREMIE TYPE TO BE USED: 0 AUGERS 'HOSE <br /> 0 AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING O HAND AUGER GROUT SPECIFICATIONS:-y a A-V C <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH '75 '/5d/ XBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? -O'> (if YES,list specifications here): <br /> *COMMENTS: LOC_LL MW-3S 15 A Deep Wa 7o 51,�, 4F A Ce rnw1.45 CAyeyL leu L�Cer�r[+�e+.),7areest Ta+4T <br /> W tnL WILD .'SC- am P' t`7 J�.' 5 Ate+ A A_A oT " To SC46Fr �(IFL�`SATFI'S�'>•w-+-S Zd`.t�- <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 /> Signedx � _ Title/Company Prt.osear FIFO C6"5r / SECar <br /> Print Name ^ ^'S Date M�+teLfi 3�Z eo3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �/� 2 <br /> Application Accepted By7) Date Issued 7' LQ/ 300. Area <br /> Grout Inspection By Date Final Inspection By 4 Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Z101 I 4. K M sR# It q <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />