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1L/��I Lt7bG lb: bL dy� r 11- I H FLUUK N96L U3 <br /> 1P <br /> ` l� ��� WELL Pt�RtllttT A►PP!_tC�TtON FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (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 /> ,pplication 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 /> Daquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> JELL Location 34 31 S. A i F Po f INCL�L Cross Street -} City atlJL�{ y I 1 Zip�SZU�� arcel#/-7 <br /> ROPERTY Owner�+l-Cd l f(i�CUS Da ce�I f Vf�Ul� dressl19 311 A;r(LC s l WT ClrvS Oc.fo rN Zip q X1 06 Phone# y9,V�3, ,33q <br /> 03w;9 7- <br /> -57 Contractor?(eni - Pn Sal, rt Address/Yoe)S' 5-0 f, City ; and Zip qyW Lic# Phone#5/0,L- NS�S <br /> 13�vd.Si-�7DG <br /> •onsultant/Sub Contractor PR r.Sa nS Address 2 I Z ,Lr_l,f:n'.P CityWn/n,;fCrrei^ Lie#41R" Phone# q2!q"t 1"3:'C I <br /> dS Coordinates:X Y Township IA/ Range 1�le_ Section 2-3 <br /> 1ORKTO BE PERFORMED: <br /> NEW WELL/BORING(CP EOPROBE, YDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(choose type below) <br /> # [I OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> ether: Grout Specifications: <br /> .OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA_OF BOREHOLE 2,S- MULTIPLE CASINGS?0 YES 00 WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [J STEEL lJ PVC Q OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 13 HOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOILBORING [J HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: n OTHER APPROX.BORING DEPTH`4 5-SL'r o BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> JJ-' /CONDUCTOR CASING PROPOSED? (if YES,list specifications here), <br /> :OMMENTS: G("� � (� �l�?r-f L,11A 6 02- r "I>`'Ca r LI I l �C° <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 /> 'iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty Ordinances, Rules and Regulations,and all applicable California State Laws./ <br /> Anes x 6 �� "k <br /> Trtle/Company, �C�I �'SrSo w� <br /> int Name— ,)' Rd!-t.1fl LlvL Date <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> 'ORK PLAN DATED: I <br /> iplication Accepted ByDate Issued ��tf'G�'` FX3 Area <br /> i�2'4a <br /> -out Inspection By U aiz--frInal Inspection By Date <br /> mtruction Inspection By Date <br /> )MMENTS/CONDITIONS: <br /> kCCOVNTING ONLY: AID# <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK# REC-D FY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> + 63 z-7 o <br /> •57 WC -WAIVER C-57 Letter of Auth riznt" n o s' n permit Encroachment doc 9/27/00 <br /> �U D <br /> �. C, �5` <br />