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WEL ERMIT APPLICATION P(-RM } <br /> .� 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 /> 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 /> Assessor's <br /> WELL Location -7,1,7S W, //"w S7: -r,4ACY Cross Street CNLISMAN RDCity ?1r,4CY Zip Parcel# <br /> PROPERTY Owner F"AYE-771E M01064C7 t1*4Address P,0, 80X 6/ City -rrte ZIPyY378 Phone# 8 31A 90 99 <br /> C-57 Contractor OoolG✓AA� Address PO, COX 374 Cityeto V/S7k Zip? SM/Lic#7/0079 Phone#7o737f���OC <br /> Consultant/Sub ContractorArC /}SSoG ATCS Address HI 7 40d45 PACrti A VECity MODES rb Lic# Phone# .S 7F <br /> GIS Coordinates:X ,Y ,Township Range Section 1 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION(choose type beIV) <br /> p SOIL BORING# Q OVER-BORE <br /> VVELL# rA LJ 7 t M W >? 0 PRESSURE GROUT <br /> *Other: <br /> Grout Specifications: <br /> COMMENTS: <br /> 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / r <br /> g0NITORING & OLLOW STEM DIA.OF BOREHOLE /1' t• MULTIPLE CASINGS?a YES 54,10 WELL CASING DIA: _ <br /> o EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS SCN q0 TYPE OF CASING: Q STEEL �VC p OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL [� r TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> p AIR SPARGE I]PUSH POINT GROUT SEAL PUMPED: o Yes U46 (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: " <br /> o OTHER:_G OTHER APPROX.BORING DEPTH /t'o a L�OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /t/0 (if YES,list specifications here): (� <br /> 'COMMENTS: SEG R-TCS 4bbi iotiAi- Soasy4,54Ca /nI✓6-E-T/r A7/onJ WoIjKP�R�1 �t <br /> 7)ihTE'r-- y .2.00y <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. \l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules an R ulations, and all applicable California State Laws. <br /> Signedx r— Title/CompanIS <br /> y l'!jy EC7 �CecOt'd /� <br /> Date <br /> Print Name - �o �� 1 /� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 75 w <br /> WORK PLAN DATED: OA{ 0 fo 200 <br /> Application Accepted By UG cs®r% Date Issued << OGS r Area f 7 5 <br /> Grout Inspection By XW .f�'s <br /> n Date / 017 05 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'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3ro� �y� /Sit 0039938 <br /> C-57-L-' WC -WAIVER C-57 Letter of Authoriz rettJ /�s;�%� ice, Encroachment doc 9/27/00 <br />