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f I <br /> WEI PERMIT APPLICATION F�F2M SITE <br /> MITIGATION r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />{ ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) � <br /> 304,E. Weber, Third Floor, Stockton, CA., 95202 R-1 ",rFL E <br /> (209) 468-3449 ��� � �� � � II <br /> NON-REFUNDABLE PERMIrEXPIRE5IYEAR A ISS E JAN 2 2 2002 - <br /> Application is hereby made to San Joaquin County for a permit to construct and/ar install the work described. This appilit i ode-in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services;E=e.iJal {�`rtku]TH <br /> at "reef <br /> 5}. FREmon7 5} ceKT+ ��ICES <br /> WELLLocadon 111 '00 E457 F �AernonCross Street E. eRo s+, City STp 9521 <br /> PROPERTY Owner I3AI GRp,wa) Address y/a0 IFRSTFRtIA42 City &/9CK7DnZip 9Sl/j Phcne#ALA �r,� %45 <br /> Orillinq 309 FittyyQrov ST. y AAWC)10 45742 `) <br /> C-57ContractorWEST' LIALrzt , Address Syi4r- A :'. Gtycerooa r Zlp Ltc#S5'y Phon 916 638 7a7b: <br /> Consultant/Sub Contractor .Ci.F . Address 957 SA{Aw A046 Gty cSTorCT0 Li-# 2 L 7 Phcn42 arr� y '/0 01 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> r I <br /> WORK TO BE PERFORMED: . <br /> y7NEW WELL/BORING(CPT.��9EOPROBE,HYDROPUNCH IAN GER.OTHER-) ❑DESTRUCTION(choose type below) <br /> ^, V.,501L BORING# P-10 I �'lI r P'12 { ❑OVER-BORE <br /> ELL# .An W-4 ❑PRESSURE GROUT <br /> 'Other._. Grout Specifications, <br /> COMMENTS: SEE AdJenywyr To w b rlc Plow/ )SATED 7 J.) Z o o <br /> TYPE OF WELL INSTALLATION TYPE _ CONSTRUCTION SPECIFICATIONS <br /> MONITORING ,HOLLOW STEM DIA.OF BOREHOLE 15 n MULTIPLE CASINGS?d YES I�NO WELL CASING DIA: Z" <br /> o EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS Sc V 9 0v1f TYPE OF CASING: [I STEEL PVC n OTHER <br /> a VAPOR MUD ROTARY DEPTH OF GROUT SEAL 3S FEL Q)(r TREMIE TYPE TO BE USED: AAUGERS d HOSE 7 <br /> a AIR SPARGE [I PUSH POINT GROUT SEAL PUMPED: ❑Yes","o (NOTE: MAXIMUM FREE-FALL DEPTH IS :.!O') <br /> SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS' 'P4rTIA wrD CEnn,.,gn+- - <br /> o OTHER 0 OTHER APPRO)L BORING DEPTH 11 1,O r BOLTED TRAFFIC BOX or ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N o (if YES,list specifications here): <br /> *COMMENTS: <br /> F. P <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 /> . <br /> 1 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 /> Signed x / Title/Company PR! a,&,T CFO/Dr3Ls� A•6. r . <br /> Print Name Tme TR Y J Cir eJAA Date 0121 Q 2- <br /> DEPARTMENT USE.ONLY <br /> SITE MAP IN UNIT IV FILE, ADD SIS <br /> WORK PLAN DATED: 27n/ ! { <br /> Application Accepted By Date Issued /�J�O - Area } <br /> Grout Inspection By. - Date / _ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS ' <br /> I; f <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DAJE PERMir r SERVICE REQUESTS INVOICE <br /> e25? <br /> C-57 W7 -WAIVER_ C-57 Letter of Authorization,to sign permitr--Encroachment doc_ .9/27/00 <br /> I <br />