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WELI ' ERMIT APPLICATION FC 111 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 Health Division. <br /> [C,�te-tt � �('� ] 1�1 Assessoo{ ' I 2 <br /> WELL Locations ,9Cross Street city�Y —Zi t-1 4 � Parcel#/�`i' -4q0 =�J <br /> tC^ o�4 c/ o pyo b C.0 O-A-" v k <br /> PROPERTY Owne7' d ss�t�p �7r__ Ciry`C— z9�' _bPnen Q(O� <br /> C-57 Contracto Y- Address\ � �IOX__Jl--A_.- -CIIy11�kv ZZi ic`4%51t5hone �1 <br /> �� Y'o'b 0L Pno �b <br /> re c ty � <br /> Consultant / S <br /> ub Contracto � ����� <br /> GIS Coordinates: X.. Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> I/WEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BQQ��ING # 1 0 OVER-BORE <br /> `]WELL #YFP � 9UYLZ - QiJ--�Ct�� l PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS /Jq tt,f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,,VMONITORING VOLLOW STEM DIA. OF BOREHOLE_0�� MULTIPLE CASINGS? DYESv�*0 WELLCASINGDIA: <br /> 0 EXTRACTION P AIR HAMMER/DRIVEN CASINGTHICKNESS 4o;O) TYPE OF CASING: O STEEL_,WVC BOTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> U AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: as 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: _ <br /> U OTHER:.0 OTHER APPROX. BORING DEPTH OLTED TRAFFIC BOX or 0 STOVE PIPE <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 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 Ordi ces, Rules an lations, and all applicable Californniia� State Laws. � L ALSE^ <br /> Signed x Title/Company (.tY'F,-' �fj' µy ( .3f <br /> Print NameDate <br /> _] d_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : <br /> WORK PLAN DATED : <br /> 1/�'/ �J <br /> Application Accepted ByTTf�?�i✓t^T� \ I t Date Issued `1 I Area I - <br /> GroutInspection % J4� Date 2 7 Z Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 35 1 8`1 B4 Ods Gtr I l `{ o SR# DOC� y a—& <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />