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ELLN..ERMIT APPLICATION F(, 'M SITE ' <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT ISI <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 3 and[he Sn is ma <br /> tanda ds of Sanrmit to construct /Joaquor in)C unty Pthe work ublic Health TServicoes'Environmental ronmental Hea h e in iDiv s on. San <br /> Joaquin County Development Title,Chapter 9 Assessor's <br /> ' Parcel# <br /> WELL Location 7175 W. /� ST, T'«C7/ Cross street CN�CISMAAJ City '77"C ZAP <br /> Ci ��c,A4cy ZiP J�Phone# 8 310 40 49 <br /> PROPERTY Owner_2E:4 -Trf M,¢q/Vfk7ULn�iAddress�O SRI 61 ty <br /> J„„1i iA,itZj Address o 0 gOX 33�_CityRto y/S?k Zip? S7/Lic#7/On7g Phone#7a737f�5/300 <br /> C-57 Contractor Z22/ <br /> Consultant I Sub Contractor A-TC &ssoGt A7F_-t Address !I f7 4,1& PAGE'+ /}t,/FCityHoDES Lic# <br /> Phone# S <br /> GIS Coordinates:X ,Y <br /> Township Range Section <br /> WORK TO BE PERFORMED: ❑DESTRUCTION (choose type beIV) <br /> ❑NEWELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑OVER-BORE <br /> I] 0 L BORING# ❑PRESSURE GROUT <br /> WNELL# MW -7 t MW >? <br /> Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Ojv1ULTIPLE CASINGS?❑YES V41.0 WELL CASING DIA: <br /> ONITOkING W OLLOW STEM DIA.OF BOREHOLE__ STEEL pp``,,� <br /> EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS ccs/ S/o TYPE OFCASING: <br /> EI TYPE❑TO BE USED:V []AUGERS❑ R ❑HOSE <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL y <br /> ❑AIR SPARGE PUSH POINT GROUT SEAL PUMPED: ❑Yes �o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS: �OLTED TRAFFIC BOX or ❑STOVE PIPE <br /> OTHER: ❑OTHER APPROX.BORING DEPTH /l <br /> CONDUCTOR CASING PROPOSED? A/0 (if YES,list specifications here): <br /> r' 7ion1 W <1KPLAnI <br /> 'COMMENTS: ONAl- SJ T _ <br /> uA ✓- <br /> ENT PERMITS. <br /> NOTE: OFFSITE BORINGS REQUIRE AC INADVANCE <br /> DAN E FOR ALLCROAR QUIRED INSPECTIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1 <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 anyrR gulations, and all applicable California State Laws. <br /> r— Title/Company —6c-,;, 4ec6e.0 <br /> Signed x <br /> Date <br /> Print Named DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2QO <br /> WORK PLAN DATED: 0'4 D 2 j�S <br /> N UG� �fl� << �c�� � Area <br /> ��-�� <br /> Application Accepted By Date IssuedFinal Inspection By Date — <br /> Grout Inspection 8y Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# �` <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BYR <br /> ]ERMIT <br /> /SERVICE REQUEST# INVOICE <br /> 350/ Mw 6-q �� qs� 0039938 <br /> C-57 WC -WAIVER C-57 Letter of Authoriz 4e 1 /e7,�to pe Encroachment doc <br /> 9'/27/00 <br />