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WELL Pmt RMIT APPLICATION FOVIA 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 Assess Health Division. <br /> rs <br /> WELL Location <br /> 67 3 2 E7-;r 1��1�"�"l �� Cross Street f"'yrh�7d Gn City Sfotl.4ov+ Zip 95 Parcel# <br /> PROPERTY Owner <br /> o ley 13o22ano Address)19/ Aler�� .lrA* ltd. City S'f ,1,4°- Zip 9S?lS Phone-, <br /> b6Q7 <br /> �I S <br /> 7-4c. S$O City <br /> ?0.7) 7y300 <br /> C-57 Contractor W/olar� QAddress ' o VS ip9SLicn7/ 79 Phone <br /> Consultant/Sub ContractorAT( ASSo[;4-FfS � <br /> �re• Address///7 LohC 64" ?vc5l� ty/U°drS><' Lic# Phone# (?09 579-,2,2,21 <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type beIV) <br /> NEW WELL/BORING(CPT ROB HYDRGPUNCH,HAND AUGER,OTHER') 0 0 OVER-BORE <br /> SOIL BORING# 3(toPf-obGA0 PRESSURE GROUT <br /> SWELL# <br /> Grout ut Specifications: <br /> COMMENTS: ( &W Sarvly *-roM eacti �ior,✓ly �' b'o-t?S QOr,ngS be �,l/t w/ 12rgf Crwtrnf �iraof 716X-4, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 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 $PUSH 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:_O OTHER <br /> APPROX.BORING DEPTH '9 S 47f• 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> // S E� Gtal'K5s ATC �Ssoria�IS, <br /> Signed x-/(/474/1— Title/Company <br /> 1t)'1 <br /> �J)) ��//��// __//������ Date 1- 6 - 0y <br /> Print Name /f/aT�1Gr 17r157)!Ie4 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESS: <br /> WORK PLAN DATED: <br /> Date Issued �"� I I 16 ` Area� 2 <br /> Application Accepted By _// / 5 <br /> Grout Inspection By Date .�-� d 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 /> rl �jc 3�`1 Cf <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sion permit Encroachment doc 9/27/00 <br /> i <br />