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WELD=RMIT APPLICATION FOO 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 /> WELL Location I WEST Wc�r�E�t h°Z- Cross Street L1`)lOL'S Ci S-rc4V-T0-j �S2oS Assessor's <br /> ry Zip Parcel# 137-370-03 <br /> PROPERTY Owner Sj0(\CW0 ROA 305- N. CtOcn S?.S""TE Z°J <br /> Address City-- I SCV-fi J Zip ')S?04Phone# CZ0914s7-�'II <br /> C-57 Contractor �` ` - 9r4 c.iw5 Address R�No <br /> 3532 t+vn6L C1,6GC6 City ct -oD„d Zip9S9YZLic#7175/O Phone#C9k�63g-1169 <br /> & <br /> Consultant/Sub Contractor.5eccnc S�-rci�t-�OM ^Address 3017 Y-t L$O&Z' 1} rAIIpros <br /> City C Lic# Phone#(Ylb)5-1-1-0 1100 <br /> GIs Coordinates:X ,Y ,Township I N Range 6 G Section 10 <br /> WORK TO BE PERFORMED: <br /> 7QNEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# 56-1 Tvk+ 64 S6-6 D OVER-BORE <br /> 0 WELL# / 0 PRESSURE GROUT <br /> *Other: Grout Specifications: �'3S <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 'HOLLOW STEM DIA.OF BOREHOLE $ ' MULTIPLE CASINGS?0 YES )rNO W ELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS N'p` TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Np” TREMIE TYPE TO BE USED: VAUGERS <br /> 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0HAND AUGER GROUT SPECIFICATIONS: Ne�-%­- Cemt�i <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH Ssy 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /JD (if YES,list specifications here): <br /> 'COMMENTS: <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 /> — <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 x -�Z'`' Title/Company P� �T C7e O�&S.ii, S l�.t <br /> Print Name 'f7"-0^^AS Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / <br /> Application Accepted By nC Date Issued A rLN ` ) Z0 0'3 <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By V lr-r�TpDate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> �erw <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 20 O y6g REC'D 0 0 SRIt S 2- 142 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />