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WELL�liii-i�RMIT APPLICATION FOS SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> rte? <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 made in compliance�wjVi San -- <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of Sari Joaquin County Public Health Services,Environmental Health Divisiol) <br /> / Assessor's <br /> NELL Location o231s N. 1.L�\', cr,�S, Cross Street City�iocrz�o:J Zip +5X <br /> 0 ! Parcel# t a5- 100-I, <br /> PROPERTY Ow�� /Inertt ?. �P r�.1 V�ua��tt Address (oo�3Q ",7-zr ne't NJ;- cit �o���of Zip ` 7 Phone't(.7-fb V'1'1-34'1 t <br /> C-57 Contractor\/ !:)2.«.rzc, Address�l7.���C elle City:.S3 Zip I Lia-W-14 Phone- 9►G) 01 <br /> Consultan Sub Contractor(4''OLCC CXt7rCM,,3i(& Address7)gl R,y,z2 \2�. Cityllb_- -i, lic# Phone# 53% (-qa4 <br /> GIS Coordinates:X 'Y- Township Range Section <br /> WORK TO BE PERFORMED: <br /> 11 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choos a below) <br /> U SOIL BORING# U OVER- E <br /> ItWELL# MPJ-��\ aPRE UR GROUT <br /> "Other: Grout Specifications: A <br /> COMMENTS: SCC A vvAcct n w��K��iiJ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING Il HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?OYES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC. p OTHER: <br /> 0 VAPOR j MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> U SOIL BORING 0 HAND AUGER_ GROUT SPECIFICATIONS: <br /> 0 OTHER: 11 OTHER APPROX.BORING DEPTH Il BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: L')OQK <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordies, le and gulations and all applicable California State Laws. <br /> Sined x / / <br /> 9 `v t TitWCompany t O t `_G G <br /> Print Name R-a a./ytd a �+ 4 t� Date q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued Area <br /> Grout Inspection By Date Final Inspection By DatejL <br /> Destruction Inspection By Date <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REM ED CHECK* REC' BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> ,C) 2 Ott S z a ( '2 5 g <br /> C-57_ WC -WAIVER C-57 Letter of sigA permit_Encroachment doc 9/27/00 <br /> E0 ��Jtid d00-l-� HiAIJ EEbE89b60Z 99:ET 100Z/8Z/Z0 <br />