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• - <br />MAY 7 2 O (1.1 <br />EN\RRONMEI,,..:‘ riERLTH <br />pERIVIVIIS ARCEWELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH blVISION (PHS-EHD) <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 r lade in compliance with San <br />Joaquin County Development Title, Chapter 5-1115.3 and the Standards of San Joaquin County Public Health Services, EnvIror rental Heath Division. <br />/ • Assessor's <br />WELL Location "tiV-43 Ittilitte(4we SB Cross Street IA 1v€- City S-10CALI-0744 Z.p ParceIS <br />Si-rtiltSIPtoS <br />PROPERTY Owner Address,RZI 5 /(.1,_F(clockark) 34c.e2:1-- City SlcselAux.), ZipCfc"40,2 PhoneS qn —R3oc <br />C-57 Contractor SCOITYVK rydoothet"Adcress24,..5 164J-tem. Drtue CItyGide-frixd Zo LCS57.224•F(P•fisneS 425-9 71 2, <br />Consultant 1 Sub Contractor TrA.)-tuti. ?etc> Address 1-11)-1 Sifee-+ Cit1Fs6J(../Ki LiaS Phone31 rt <br />GIS Coorcinates: X Y ,Township Range Secitr <br />SITE <br />MITIGATION <br />UNIT IV <br />WORK TO BE PERFORMED <br />AlEW WELL t ecRiNs (CPT. GEOPROBE, HYDRCPUNCH, HAND-AUGER, OTHER') <br />a SOIL BORING <br />WELL yvvAi <br />O DESTRUCTION (choose type below) <br />a OVER-BORE <br />0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS: <br />TYPE OF WELL <br />XMONITORING <br />U EXTRACTION <br />VAPOR <br />1:1 AIR SPARGE <br />U SOIL BORING <br />['OTHER: <br />INSTALLATION TYPE <br />-1OLLCW STEM <br />C AIR HAMMERDRIVEN <br />MUD ROTARY <br />fl PUSH PONT <br />C HAND AUGER <br />OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DR. OF BOREHOLE " MULTIPLE CAS NGS7Q YES 0 NO WELL CASING OR: 11 <br />CASING THICKNESS atet 116 TYPE OF CASING a STEEL ;KPVC OTHER: <br />DEPTH CF GROUT SEAL 1' TREMIE 71,PE TO BE USED: AAUGERS p HOSE <br />GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: illigr.A.•k Cet4,4i•4i lAY 57. beittim.i.te <br />ARPRCX. BORING DEPTH -'3S1 (An XEOLTEC TRAFFIC BOX or p STOVE PiPE <br /> <br />,-, CONDUCTOR CASING PROPOSED? ( IYES, is: spes.ficaticns here). <br />5e/Le21—\ /-D -r-f?-c4 • <br /> <br />'COMMENTS: <br /> <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 <br />County Or man les and Reg <br />Signed X <br />this application and that the work will be done in accordance with San Joaquin <br />ions, and all applicable California State Laws. <br /> Tit e/Company ,N4-#6eD/Osis 1/67/vivi2.,ero <br />Print Name Seem-I (---ct-ruti) Date hrta,t_., 14 12001 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />cowl <br /> <br />j <br />Application Accepted By Da:a Issued Ma 75, 0204D) <br />CroJt Inspection By Date •45/00/0 I Final Inspettion By <br />Area <br />e Dat a/44.4k, <br />Destnxtion Inspection By Date <br />COMMENTS /CONDITIONS: <br />ACCOUNTING ONLY: 1 AlOrt PACS <br />.• <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS REC'D BY DATE • r IT /SERV! ---•-/ • Ft INVOICE <br />3601 ir\W oc) Ow `1 I' 14krb,C : <br />C-57 <br />WC -WAIVE. - C-57 Letter of Authorization to sign pe-mit .Encroachrn 9/27/03