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.i <br /> 4 � ) - <br /> WELL - PERMIT APPLICATION Fu , ZM 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 'I 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 with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> n T Assessoris <br /> WELL Location 3,, 1I1t'17 sdDpU't�C It DOrndc': Cross Street + P live City SSP k4 � Zip Parcel# <br /> PROPERTYOwneryGti'l �Q_ \ C` (:^ +drpC�4'S Address 1 () &) l( n1 �V � City S-Ir0C61 Zip 75AGYhone# �/&Y5 34ZI <br /> C-57 Contractor �Jfe <br /> ct 4 Zn S' is Address 9SO k"e I 6 Cityn 4Iner. Zip 9YSn Lic# (016'?0IPhone# ?ZS 3t3 -ST8G6 : <br /> Consultant / Sub Contractor AWtncJ C�eoEnutrotKr; Tress 937 Slew Rr?( City S{ !(,Af{rcn Lic# 6Pr0�lI Phone# LI (., 7 - ) 666 <br /> GIS Coordinates: X , Y., Township Range Section <br /> W <br /> rCO��RK TO BE PERFORMED: <br /> pm WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br /> O'SOIL BORING # P 5 _ K— r /, 9 p OVER-BORE <br /> B WELL # 0 PRESSURE GROUT <br /> 'Other- Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA. OF BOREHOLE Zn MULTIPLE CASINGS? 0 YES a NO WELL CASING DIA:_ <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC B OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL IXS' F-T TREMIE TYPE TO BE USED: B AUGERS a HOSE <br /> 11 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: vyes p No (NnnOTE: MAXIMUM FREE-FALL DEPTH IS 30' ) . <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS: POr�' k1k NY <br /> Q OTHER: O OTHER APPROX BORING DEPTH \ ' FT 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> p CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> 'COMMENTS: C ` 1T auras <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 Orrodinn�nces, Rules and Regulations, and all applicable California State Laws. fl <br /> Signedx�fr`7K't-� � � /� Title/Ccmpany !!qu rnlf'Heg4 ' Yeceyl stl6�a'tnncary GeD <br /> Print Name 01h,S 'M pker 12- AA . t1Qr Date -CJ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3 /q ? ZifQbv�ca- sf <br /> WORK PLAN DATED : Z ?,Do 1 <br /> Application Accepted By Date IssuedArea Z �Z <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: , AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'O BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 350 ! `6 % 79 1 /5Z7P t;02-622o <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />