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'-`I ''Fu1Lulk UKIUINAL <br /> Wo r,PLA0LL PERMIT APPLICATION FOKM SITE <br /> w MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) REC_304 E. Weber, Third Floor, Stockton, CA., 95202 - -/ <br /> .�� n <br /> (209) 468-3449 AUG0 <br /> 72002r <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 appGh8R0i&WcbhxtaaliFe with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,EpFRWM9vision. <br /> ,11 ��I `^wn��� Rssesso s q <br /> WELL Location ZZ W L�►J YV !4 Cross Street(� CityZip'c�Parcel# / <br /> P <br /> PROPERTY Owner SIJ C11- MCnj4l ddress SA A4 P_ City Zip_ # <br /> C-57 Contractor JSfZ_F _t_ 4 -1� W t37 Address q65 FWwe-Q-p City j4AAg jMM Lic 640hone <br /> Consultant/Sub Contractor[wTl-I I L- E-0 Address J Z74�J FA-( DU CY-t—�C ty b D Lic# iftZS�Phone 3� 1 <br /> GIS Coordinates:X Y ,Township Range Section <br /> W9EK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH�,HAND-AUGER,OTHER-) a OVER-BORE <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> 0 W ELL# tl,1(0)_ <br /> *Other: Grout Specifications: <br /> CJMMENTS: <br /> TY OF WELL INS ALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0LLOW STEM DIA.OF BOREHOLE_ MULTI E CASINGS?;�ES 0 NO W LL CASING DIA: It� <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL C a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERSSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1 <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH 1061 <br /> OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED7 (if YES,list specifications here): i <br /> 'COMMENTS: <br /> Kv✓ �! <br /> NOTE: O FSITE 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 Ordin ceS, Re ations, and all applicable California State Laws. <br /> Signed x <br /> Title/Company <br /> Print Name 7; 1&4_&&J t T Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> l ill• 144oLAIL <br /> GvP <br /> /11 <br /> WORK PLAN DATED: 'l P'D Z �f <br /> A 17 <br /> Area a <br /> Application Accepted By <br /> Grout Inspection By Date Final Inspection By Date <br /> Date Issued <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: C7V <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> � � � 3�3 z-• 8.7.0A n3"N/Y f,� <br /> ✓Encroachment doc N 9/27/00 <br /> C-57 WC_--WAIVER C-57 Letter of Authorization to sign permit <br />