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WELL , _RMIT APPLICATION FG_ ..V1 SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> AANYANMENTAL HEALTH DIVISION (PHS-EHD) <br /> 2ttgva k 304Z.Peber, Third Floor, Stockton, CA., 95202 <br /> �0 r co\ ,N A4 (209) 468-3449 <br /> st>,��d1"?'aµp�,a�cM�N <br /> c 4DE NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby M 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 /> 1 Assessor's <br /> WELL Location 1�3z� 5• Vw^ ,41i� Cross Street E. &A6kN (Zd City L Sc.,/a h Zip SS3� Parcel# Z-0 S O.30 ZS <br /> PROPERTY Owner RAev+ M4tIwS Address 14323 S. V4, City EScsto-+ Zip`K32-c) _Phone# 2'yj'b 9.4( 3 <br /> C-57 Contractor ri5c� YtivivoM�+c X41 Address S�vis �+�r� City U-,��cx Sim-q ipgSZSZ Lic#�if3r1S Phone#2i7°/ 4is2-;$7d <br /> Consultant/Sub Contractor/ATG 415;Qc -4pY Address City e Lic# Phone#"-535-222/ <br /> GIS Coordinates:X ,Y Township T S Range q C Section 3� <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, EOPROB YDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type belcW) <br /> S BORING# SII 1 , SR 2y 5+3 '3 1 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Saecifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2' MULTIPLE CASINGS? 0 YES )(NO WELL CASING DIAAA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS AIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: AIA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL +1),,W0 'TO' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: /Ve•-3- <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 10'.10/-, `q-J 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 1I CONDUCTOR CASING PROPOSED? A/0 (if YES,list specifications here): <br /> 'COMMENTS: r7ca Probe , -twv -Io to' , c)ne It, -50 <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, R-ulleeess and Regulations, and all applicable California State Laws.Signedx /6../ Title/Company S , I C�Ioa. IATC /tSSacla.7ef <br /> Print Name +vh ��r' <br /> �� r� Date Fa� II �U17S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_I 33 2- - ya ►,. ,4(l <br /> WORK PLAN DATED: 7- <br /> Application <br /> Application Accepted BDate Issued 2-I 1 S� 1 C9 Area 2- <br /> Grout <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# ,. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a�r�l T4s •da Tgc( tA, z �s ' Z <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />