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WELL(�ERMIT APPL' MATION Ft M <br /> SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> AA <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor,• Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Apptication is hereby made to San Joaquin County fcr a permit to construct andror 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 Health Division, <br /> Assessor's <br /> WELL Locatlon 28Ct} E. Frc.rAaA+St. Stvci6l Cress Street r�i 14nLG't City 'S -L.t--on Zip Parcel# <br /> i <br /> PROPERTY Owner ie per Address ZS04 9. 1~rc-yv eA`E' St city atocLth6 zip Phone# ciY6-"07-1"T, <br /> r <br /> C-57 Contractor Figj, Address -3cCityU kor4�-'ip Z 2-Lic# 38GS Phone#__777--32'Q <br /> Cons uitant1Sub Contractor ATC— AS5oc, l lr__`Address 1.117 Lnmg.'fAlm *8 City o sfo Uc# Phone# "-•Zz--Z- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED <br /> - <br /> 0 NEW WELL BORING CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type belcW) -' <br /> SOIL BORING# Z D OVER-BORE <br /> U WELL# D PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ` <br /> 4 ? <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE 1.s MULTIPLE CASINGS? DYES D NO WELL CASING DIA:�� <br /> 11 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS �-N IPir—TYPE OF,CASING: H STEEL D PVC O OTHER: AJIA-- j <br /> []VAPOR D MUD ROTARY DEPTH OF GROUT SEAL �1- 1?0 r TREMIE TYPE TO BE USED: 0 AUGERS ,WHOSE ' <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED:+AYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> qylklt-BORING D HAND AUGER GROUT SPECIFICATIONS: t-Wk' JS AtClf t-U; G rou'I <br /> D OTHER: 11 OTHER APPROX.BORING DEPTH N `101 D BOLTED TRAFFIC BOX or 1]STOVE POPE <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 INSPECTION011111*, <br /> I hereb Y certify that I have prepared this application and that the work will be done in accordance with,San I& <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. . <br /> Signed 9 _T`itl.&Company TC- SSoC– /I-L <br /> Print Name Date o <br /> ©EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: -6-1 Imo{ Io <br /> ApplicaUcn Accepted By Date issued "L of Area <br /> Grout Inspection By Date Final Inspecticn,By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS ICON OrTIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> # <br /> R0 0 9"T. i <br /> C-57 WC -WAIVER C-57 Letter of Authorization to 5ign permif Encroachment doc 9/27/00 <br />