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WELL ,'RMIT APPLICATION FO, ,A SITE <br /> % MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <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 Heth sDivision. <br /> AssesWELL Location <br /> -76-75- W�►S f Elt vtn fl, Cross Street (k/iswoan 2d City / .-e, Zip `/530 Parcei# <br /> ,f le. (,/OV« Address P V• 6O'k /OSS city—T,-acy zip?5-3 LL <br /> 72Phone# --k <br /> PROPERTY Owner /' <br /> y,/ 399 Sti[%I�S �/4c� City✓ii1/t �••n ip 9S1S�? Lic#6838 Phone# (5o4)77Z-.3570 <br /> C-57 Contractor f r S[A En t/I r0,1,W eA�tldress --�e <br /> Consultant/Sub Contractor <br /> 4t7C 4ssor'A4rs rc. Address ill-7 [-ont t4/r„ 4,ity '%S4- Lic# Phone d°9) 579-; ?2/ <br /> Y Township Range Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED- DESTRUCTION (choose type beloV) - <br /> -g NEW WELL GRIN (CPT, EOPROS HYDROPUN3CH,HAND-AUGER,OTHER-) 0 OVER-BORE <br /> SOIL ORING# 0 PRESSURE GROUT <br /> DWELL# J__t .. .r,/ <br /> 'Other: Grout Speecifications: /Lc. <br /> � <br /> COMMENTS: 411 441r-c< b ort Y1M <br /> ;N v ar+ A O / 97G ?S T'•C[� ��/iw rivrJtvr{�c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NO WELL CASING DIA: <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1" MULTIPLE CASINGS. OYES 0 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ►J R TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:_ IJPS <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> ❑ D: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE `PUSH POINT GROUT SEAL PUMPE <br /> 'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> ❑OTHER:_O <br /> OTHER APPROX.BORING DEPTH �Jr I� ZDV 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> • CONDUCTOR CASING PROPOSED?�1 V�-_{if YES,list specifications here): <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 /> ,J/ Title/Company Sta f•F 6 edo q is f Z,4Te 4S5oc,4{[sTnc• <br /> Signed x A v'q� _0 <br /> ,�/)) � �•� 1 Date 3 - �' y <br /> Print Name /tea aY1 l..Yl/'IS'!'►'»d►� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 76 5 w• <br /> WORK PLAN DATED: 03 DAI/A D <br /> Application Accepted B ) ` Date Issued <br /> Area <br /> 4 <br /> Date_ -- <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO I AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3561 S8 � 89 ��7 CINT IZ �03 D'f v o-2. 7 I�o <br /> C-57 SNC -WAIVER C-57 Letter of Authorization to cion permit Encroachment doc 9/27/00 <br />