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f# <br /> ` r <br /> WELAPERMIT APPLICATION F(,- M 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 Hellth Division. <br /> AssesLa /�/GV Cross Street City _Zip 47S20(o Parcel#/�LS'430-/C <br /> WELL Location L+ I I /v <br /> PROPERTY Owner''UDA7 /� `-inA5 " dress �CS �OX ��� �� CitYl`�`���Zipl Phone# � <br /> C-57 Contractor I $� tt (..I_Address�� S�.Ti S �1�� City / S ip S52SlLic#-6u��hone#/iiI 7n-3 10 <br /> tiu,r,+�.. �., <br /> Consultant/Sub Contractor g'(0 i2 Address J�17 IC�4re 1 City 4..(� Cc�s�-,Ljc# — Phone#n*5 /-yi'�' <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> PTDESTRUCTION(choose type below) <br /> ,GEOPROBE,HYDROP NCH,HAND-AUGER,OTHER-) <br /> (( -IEW WELL/BORING(C 0 WELL#SOIL BORING#� OVER-BORE <br /> 5�—� Y I+�;I1Z� 0 PRESSURE GROUT <br /> 0 r <br /> 'Other: Grout Specifcations: ��F � ir <br /> o 4. <br /> COMMENTS: jf 6euptilo� �rik+.t �c ceir��C. t'6' Z h4H� Uc:cz/ bor��tt5 h !G <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" MULTIPLE CASINGS?0 YES ANO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> AIR SPARGE X PUSH POINT 118" GROUT SEAL PUMPED: 0 Yes ,KNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER 2 GROUT SPECIFICATIONS: <br /> 0 OTHER:_H <br /> OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: I( fr�1<�—�[� �.0+ 1nkk .r,+1 <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 p epared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rule a Regulations, and all applicable California State Laws. s,�` <br /> �? Title/Company S �C f �G <br /> Signed x ( nom <br /> Print Name �Z L �Ls�ti ��5 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, APDRESS: <br /> WORK PLAN DATED: 7/S0Z C�J2�✓ c g bj ZZWLS <br /> Date Issueda2� Area0/ Cr/lQ�C� <br /> Application Accepted By <br /> Grout Inspection B (d L` <br /> Date Final Inspection By Q Date <br /> y ' <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: C/YL,�.J G <br /> [ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2�'d �l � - �3�zr7 ;�� p 6 z Doi <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />