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Ei <br /> WELL ERMIT APPLICATION F06 <br /> SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) o� i�fn ; <br /> 304 E. Weber, Third Floor, Stockton, CA., 85202 U I��L`� �1-1-1 <br /> (209) 468-3449 4 AUG 0 5 2003 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM'!DATE ISSUED <br /> kpplication Is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is m� i T1 il•15An��H <br /> Joaquin County Development-floe,Chapter 9-1115.3 and the Standards of Sari Joaquin County Publ is Health Services,Environm VA, i� n. <br /> S 1 .r� �Zo n 3ZD Asses r VICES ) <br /> HELL Location �^J S�0.\O*� Crass Street Clty-��C=��� lap Parcelf# l 1 <br /> PROPERTY OwnerC;� �Sc�.lor, Address P� � �-`�� citys�alar. zip��3zoPhone#gct3$ <br /> r,57 Contractor C-�s�� Y`c ,_ Address � 1���J e \� Cit ;^ 2 Zip y�S3 Lic# ES(b�Phone# l a 5 3)3 S <br /> Consultant Sub Contractor C*�-1��`,ca �;cl Address `)p — City: 1, 1l) gt-Licl l Phone#2U9 S�L.1411 <br /> 'i <br /> GIS Coordinates:X Y Township Range Section <br /> i <br /> WORK TO BE PERFORMED: <br /> II NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHERS � 0 DESTRUCTION(choose type below) <br /> 11 SOIL BORING# S 0- c S Q3 7—_ _ [)OVER-BORE <br /> a WELL# Is 0 PRESSURE GROUT <br /> *Other. � 3- z - 0 3 Grout Spedfiications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � <br /> Q MONITORING lj HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?I]YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYP=OF CASING: 0 STEEL D PVC. I]OTHER: <br /> 0 VAPOR .0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPc TO BE USED:. []AUGERS 0 HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: i <br /> a 07HER: j]OTHER APPROX.BORING DEPTH . E' j]BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CnNIOUCTOR CASING PROPOSE[? it (If YES,fkst specifications here): <br /> ru <br /> *COMMENTS: , LJ _ <br /> if <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. t <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE r-OR ALL RE=QUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will ble done in accordance with San Joaquin ; <br /> County Ordinances,Rules and gulations,and all applicable California State Laws. <br /> li <br /> Signed x T1tIelCompany <br /> Print Name i� Date 7 12�'r % _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3{] 5 .ILe <br /> WORK PLAN DATED: Z- 2-00 :1- <br /> Application <br /> D Application Accepted By Date Issued IE f` E Area <br /> Grout Inspection By Date Q O Final Inspection By Data S <br /> Destruction Inspection By Date I[ <br /> COMMENTS I CONDn-iONS: (/t S C� S ) FT OT <br /> ACCOUNTING ONLY: AID# <br /> fl <br /> PE CODES FEE INFO AMOUNT REMITTER <br /> CHECKS REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57WC -WAIVER C-57 Letter of Authorization to sign Fern it—Encroachlnent doc 4/27/00 <br /> EO 39Vcf EEbEB9�69Z 9S E� 1(39Z/Bis/Z9 <br /> I� <br /> i <br />