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WEL�PERMIT-A�PL'ICATION F M <br /> SITE <br /> MITIGATION <br /> U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> R UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> JAN 2 Ot�1 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449ENVIRONNI <br /> �V <br /> PERMfT/SEKCES NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1. <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 Devzloprlent Title,Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> Assessor's <br /> WELL Location1876 Cbmtr�y Club Mme- Cross Street Vh.SS1Cn CityS Crl Zip Parcel# LZIZXx�n <br /> PROPERTY Owner Mr- & M-S. I4tLta1 aTr-1-EZAddress 1633 W. Ln}dJnl t - City �jCC1{tGZ7 __Zip 95203_Phone# 209_464-1291' <br /> G-57 Contractor V.W Address P.O. Box 51 Cit O Vista Zip 94571 Llc#720901+ Phone# 707 3742815 <br /> Consultant/Sub ContractorlieSte-M req-11 i eer S Address 1386 E. BewEr St City ndt ic# 51 Phone# 5.30 668-5-DO <br /> GES Coordinates:X Y .Tovrnshlp 1N Range, 6 Section 4 <br /> WORK TO BE PERFORMED: <br /> XNEW WELL!.BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a DESTRUCTION(choose type below) <br /> 17 SOIL_BORING# (I OVER-BORE <br /> SWELL# I]PRESSURE GROUT <br /> `Other: Grout Specifications: _ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MON#TORINGi IjHOLLOW STEM DIA.OF BOREHOLE n MULTIPLE CASINGS? []YES JRNO WELL CASING DIA:)4t? <br /> o EXTRACTION j]AIR HAMMER/DRIVEN CASING THICKNESS SCh 40_ .. TYPE OF CASING; O STEEL 1@ PVC Il OTHER: <br /> [J VAPOR MUD ROTARY DEPTH OF GROUT SEAL 71" TREMIE TYPE TO Bin USED: [i AUGERS HOSE, <br /> 0 AIR SPARGE []PUSH POINT .GROUT SEAL PUMPED: 0Yes 1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS: neat CiClftlt with<5°l0 l]H7t(111t2 _ - <br /> 1f OTHER: hEter a OTHER APPROX.BORING DEPTH 301 BOLTED TRAFF=IC BOX or p STOVE PIPE <br /> r,emvery CONDUCTOR CASING PROPOSED? nO (if YES,list specifications here): <br /> *COMMENTS:- <br /> NOjT 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 Ordina_61 , Rules Regulations, and all applicable California State Laws. <br /> Signed x TitlefCompany �T7 Ceo-Bjgg eem <br /> Prt Name Date f- 2 3 -�247cz, <br /> DEPARTMENT USE ONLY i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORKPLAN DATED: V <br /> Application Accepted By Date Issued <br /> 4" Area Df[J <br /> Grout Inspection By Date Final Inspection By to Z ' <br /> Destruction Inspection By Date <br /> COMMENTS J CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I S VIC EQUE # INVOICE <br /> J—_AV� <br /> C-57 WC -WAIVER C-57.1-etter of Authorization to sign permit Encroachment dot 9/27/01, <br /> FC7 �rrCd cLG1 F�_I� - <br />