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WEE' ?ERMIT APPLICATION F ' RM SITE <br /> NIT IV <br /> SAN JOAQUIN COUNT`( PUBLIC HEALTH SERVICES UNIT <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) i�RI�T <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �(�;� <br /> (209) 468-3449 00 <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 i itle,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessors <br /> WELL Location 7675 ,t WfSf i'^/Pver►A-54Cross Street (kr Sinan 2d City I t A-e Zip `x530'' Parcel# <br /> PROPERTY Owner Or. 4• de. &/O✓trAddress P V, 6OX /OSS' C1 Tracy Zio?5372Phone#(F.01 <br /> C-57Contractor F,seb, Eny;r0v14?f4' //dress 399 Shfr•)`s JOAZOE City AllcSri»81p JS.IS.2 Lic#6�3g6Phone# (log)77�-.3570 <br /> s <br /> Consultant/Sub Contractor ATC 4ssoc;4lec rm e, Address 111 7 t-ont John 41�ity /ale%sem Lic# Phone#( °9) 5 79'-V?�pl <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> -g NEW WELL BORIN (CPT, EOPROB HYDROPUN CH,HAND-AUGER,OTHER') DESTRUCTION(choose type beloyv) <br /> :lICSOIL ORING# 3 0 OVER-BORE <br /> 0 WELL# PRESSURE GROUT V} <br /> 'Other: Grout Specifications: /Veat <br /> COMMENTS: Alt fhdfe,44 e,[ 1 S' ?5 -ee4- L11w yr�rx/sv.+4oc <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I" MULTIPLE CASINGS? 0 YES ONO WELL CASING DIA: iUi4 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 1J R TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:_. (� <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE \ <br /> 0 AIR SPARGE IdPUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 15'- 2-0'_0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NA- (if YES,list specifications here): ��rl <br /> T <br /> 'COMMENTS: <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 /> 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 and Regulations,.and all applicable California State Laws. <br /> Signed 7T­4-A^ S1`a`� F Geo%,915f 1ATe- �7SSoc�o{fS Tnc,` <br /> Print Name /0a 401 Yl CAr t$- ✓M A#1 Date 3 - -0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 0314)'`f loo <br /> Application Accepted By Date Issued D Area <br /> Grout Inspection By—M-1a �. . Date 8 Fina!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 /> 3501 S8 $9 SS 7 CWT IR, 03 o'f 0 0 3 7 I"It o <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sion permit Encroachment doc 9/27/00 <br /> i <br />