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WEJ PkRNIIT APPLICATION URNI SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION " <br /> j ENVIRONMENTAL HEALTH DiviSiON (PHS-EHD), UNIT I'V <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE IS ESLE COPY � <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 41175.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location C $I(ee+- - S},¢.t} Assessors <br /> yl z 0 LA-3f EA ono cross Street o t` city S%tics'�nr�Zlp 5a I5 Panel# <br /> PROPERTYOwner Valbif lire. ' Address //Pp nnT �i c,.,�,s•}S1Clty_KSIOC �o.n/Zip Q>IIT Ph one# Oct 9blQce40p <br /> C-57 Contractor A.G. a Address 637 si+6w rt�RO' City.5 TotK To.- Zip 9�Z17Ur.# .7227Phanelrt>`) 4b 71�e b <br /> consultant]Sub Contractor f7 U Fs Address 1%7 S lfgw !S a/10 CityTn Uc# O ZZ hcne42 a5) V b 1 o r b <br /> GIS Coordinates:X ,Y ,Township'1 3r Range Section <br /> WORK TO BE PERFORMED: ��----���� <br /> EW WELL/BOR ING(CPT.�G9E9_PFiYDRO�If(J�NCH,HAND-AUGER,OTHER') Q DESTRUCTION(choose type below) <br /> SOILBORING# 1 fc�.. * 1]OVER-SORE <br /> /DWELL# Q aPRESSURE GROUT <br /> 'Other. Grout;Specifications: Tk.n <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE _ CONSTRUCTION SPECIFICATIONS - <br /> o MONITORING 1]HOLLOW STEM DIA OF BOREHOLE -2" MULTIPLE CASINGS?[]YES ]INC WELL CASING DIA:^ <br /> o EXTRACTION 13 AIR HAMMERIDRIVEN CASING THICKNESS N/A- TYPE OF CASING: ]]STEEL 1]PVC H OTHER: <br /> a VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL�r�_TREMIE TYPE TO BE USED: 1]AUGERS XHOSE <br /> I]AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 11 Yes 1, to (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> $SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: Pn +:l 41 C('MQ✓I}' <br /> R OTHER R OTHER APPROX BORING DEPTHi(o'S� 1]BOLTED TRAFFIC BOX or 1]STOVE FIFE r. <br /> e / CONDUCT(Jp{�2 CASINGr�PROPOSED? N/F} (if YES,list specifications here): <br /> 'COMMENTS:�L rL- A !Pf O VCD Ihl 0 r K I r"� W'}f I a, <br /> r <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 andel Regulations. and all applicable California State Laws. A / <br /> Signed x /�h11/8+1� / / , W' TitlelCornpany �('C 1 ��nl P�f SJ / / lJ: <br /> ra <br /> Print Name / I �s CVS LN/�rA - .: Date j/A 0A <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /h/� /'moi-i✓� <br /> WORK PLAN DATED: <br /> Application Accepted By • Date Issued 7�,32— - Area <br /> Grout Inspection By Date / � r ' Final Inspection By - <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: 'l -- <br /> i <br /> ACCOUNTINGONLY: AID# ..Y <br /> I <br /> PE CODES FEE INFO AMOUNT RI 61MED CHECK# REC'D BY DATEPERMIT I SERVICE REQUEST INVOICE ) <br /> i Z 76. / b <br /> C-57 WC=WAIVER_ C-57,1-etter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />