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WELL P'rrRMIT APPLICATION FOR, ll 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 /> ,pplication 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 /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental <br /> He l sDivision. <br /> YELL Location (-73 a fq � way F8 Cross Street F,-r(0)l„�� �n City Sia k foh Zip 9s Parcel# ` <br /> M L 1(• Qa224.�o Address 2$9/ N°rfll f}rai<* �'d City <br /> 'ROPERTY Owner s�tltfoh Zip 9S7I/SPhone#C�Og) 93�-ac97 <br /> f. o / <br /> 57 Contractor_ , 11 CO, `�50 H0`1f ZipyYs53 Lic#` 9-5 Phone# 9 5 �1 3 5800 <br /> G/f4q ��h4 Address <br /> lie <br /> 'onsultant/Sub Contractor A T(- Address 1I17 Lont 64- City A411)--S -° Lic# Phone# <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> NORK TO BE PERFORMED: DESTRUCTION (choose type belcW) <br /> ff NEW WELL/BORING(CPT GEOPROBE.HYDROPUNCH N -�pT.OTHER-) 0 OVER-BORE <br /> ff SOIL BORING# 0 PRESSURE GROUT <br /> 0 WELL# - <br /> Grout Specifications: <br /> COMMENTS: 2 &W 3 s.;! S4&Vi01f3 f>-6 C r7- Bor;nj. 7o b< vb 4'/fe w/ ht4f rtmcnf- v/ ¢� Svr{�iGc. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 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: GAUGERS 0 HOSE <br /> 0 AIR SPARGE $PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> fI SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH / ;0 4t. 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 /> J � Title/CompanySfuE->< Gta�o /S� / �T� �Sta�i4�'S i.Tnl. <br /> Signed x /Vim? `^`- 9 <br /> Print Name /1'/GAAh ��r/Sf�'I9+� Date �— 6 — y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, APDESS: .3 ;)- <br /> WORK PLAN DATED: 1 $ 0 + <br /> Date Issued a-I I I L` Area ?� <br /> Application Accepted ByDate / <br /> Grout Inspection By Date 3 Final Inspection By - <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 /> permit Encroachment doc 9/27/00 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign <br />