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PERMIT / SERVICE REQUEST #
<br />PE CODES CHECK #
<br />0 sR# 29IV CK9.0.4' 3 <0 0137,-7
<br />-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc
<br />AlDti ACCOUNTING ONLY:
<br />AMOUNT REMITTED FEE INFO
<br />FACIf
<br />DATE REC'D BY
<br />COMMENTS / CONDITIONS:
<br />INVOICE
<br />9/27/00
<br />C-57 WC
<br />WELL PERMIT APPLICATION FORM
<br />pAylvi EN T
<br />RE.C;EIVE 0
<br />MAR 1_ I -Nil
<br />SAN JOAQUIN COUNT(
<br />PUBLIC HEALlii SERVICESI
<br />,
<br />DVIbiCitii NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />kpplication 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 ciTj9C1t•it,11:rili-L .. .
<br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division.
<br />\\•,.Q 1 5 *-- Assessor's
<br />NELL Location3-1 O\..i ,k__:. N r, p. r?_J--- Cross Street '3. W, c.A RA City 1-C ci". (.;,.) Zip C1 S -3 -110 Parcel#
<br />_J
<br />PROPERTY Owner S; ,--..t....\c k ; c Address L: f\-,-. (Li'l, City 1 C oNc --) Zipe1511l,Phone#
<br />'2-,•J9 --1 C\\\
<br />C-57 Contractor 8- Ni\I \)r-,1- ; \\ c--..Ac-Address ? '7) iC- :si i•-• '•-=1.1 La City ' ZIP '..'srolit_ic# Phone# -1-h 1 -
<br />Consultant (Sub Contractor C.-"--io 1 .vii,-; ..;, rd. "t-,13•N inii,,Aidclress•
<br />,...,
<br />GIS Coordinates: X , Y , Township Range Section
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD)
<br />304 E. Weber, Third Floor, Stockton, CA., 95202
<br />(209) 468-3449
<br />SITE
<br />MITIGATION
<br />UNIT IV
<br />City Phone#
<br />WORK TO BE PERFORMED:
<br />NEW WELL/BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*)
<br />fl SOIL BORING #
<br />N WELL #
<br />*Other:
<br />COMMENTS:
<br />El DESTRUCTION (choose type below)
<br />OVER-BORE
<br />a PRESSURE GROUT
<br /> Grout Specifications:
<br />C,
<br />TYPE OF WELL INSTALLATION TYPE
<br />MONITORING HOLLOW STEM
<br />EXTRACTION 1:1 AIR HAMMER/DRIVEN
<br />0 VAPOR fiMUD ROTARY
<br />0 AIR SPARGE 0 PUSH POINT
<br />fl SOIL BORING a HAND AUGER
<br />El OTHER: OTHER
<br />CONSTRUCTION SPECIFICATIONS
<br />DIA. OF BOREHOLE MULTIPLE CASINGS? DYES fi NO WELL CASING DIA:
<br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:
<br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE
<br />GROUT SEAL PUMPED: ['Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30')
<br />GROUT SPECIFICATIONS:
<br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE
<br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here):
<br />*COMMENTS:
<br />
<br />6-'11
<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 this application and that the work will be done in accordance with San Joaquin
<br />County Ordinance yzRuleis ars! trrns, and all applicable California State Laws.
<br />4 -_,'\j ,... „..,...,_
<br />Signed x Title/Company I l'N S ,,,..\,kr-Avs,1-.t J (--Yj I —1
<br />Print Name R.-..c;\ ,,i; n \,\d\-• V--(A\o\oi-n-\) ..."\.) Date )1-3I -0 ---
<br />J DEPARTMENT USE ONLY
<br />SITE MAP IN UNIT IV FILE, ADD ESS: 1--5? 0 i ei IA 1?"‘ 6-4 12 "en,' •() •
<br />WORK PLAN DATED: C, ( C\ OC,
<br />Application Accepted By
<br />Grout Inspection By
<br />t/f:;41/1.4.,tr0W--
<br />
<br />Destruction Inspection By
<br />ES 39Vd elOOld HIAIA EEVE89t,60Z 9S:ET IBOZ/BZ/Z0
<br />Date Final Inspection By
<br />I qi 0' 2— Area
<br />Date
<br />Date Issued
<br />Date
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