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PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> OCT 1 6 2003SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (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 /> �, Assessor's Z19- 3fs4-Z3 <br /> WELL Location y/9 S iG1,r/� -�``/,,KLET Cross Street R1,eTM0R� City �� �' Zip .S9 334 Parcel#1=-,?f <br /> PROPERTY Owner/(yLTlT ,QOBBY MAAl6AT Address y/�} S /fi/,!/,(I STPf£T City /�7,IA/T£�Zip 95334 Phone#: -209-j'e�0'/--Y L9 <br /> C-57 Contractor A£tT��/LUA1LAddress/_& _j ,�TELL�t_AVj_Cjty,4A /.N Zip JOS Lic# / s Phone# B1- V -«SU <br /> F¢it,U <br /> � 188 K W[sr 4'actL <br /> Consultant/Sub Contractor&V&2 At2II! /&t•,IAr_ Address .5u1TL t Citi K�/t� Lic# Phone#,7o�j- Z3y-aS/Ir <br /> GIS Coordinates:X Y ,Township i�5 Range 7167 Section T <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> o SOIL BORING# o OVER-BORE <br /> WELL# nZ /� 0 PRESSURE GROUT <br /> *Other: Grout Specifications: /VLAT C�.Ktd.�T <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS a H <br /> MONITORING YHOLLOW STEM DIA.OF BOREHOLE''1 D�MULTIPLE CASINGS? 0 YES XNO WELL CASING DIA:�y <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESSSCH. 410 TYPE OF CASING: 0 STEEL XPVC (]OTHER: <br /> O VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 9 TREMIE TYPE TO BE USED: YAUGERS 0 HOSE <br /> a AIR SPARGE PUSH POINT GROUT SEAL PUMPED: Ayes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1 �A 66lf,tJ7 <br /> Q OTHER:_G OTHER APPROX.BORING DEPTH -30 LAO ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �r CONDUCTOR CASING PROPOSED? A10 (if YES,list specifications here): <br /> 'COMMENTS: i� LJ/Tyx XI�LL U ZAMALTID.V &a.G INS7-ALLAr7l04.) <br /> CDV[ j" 30-l ooT Wic4.1 60" 4!" y0-6207 944) <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 les and Regulations, and all applicable California State Laws. <br /> Signed x _Title/Company CaunaR �,2�f/ �fGiS/.yULOlr1fS �.(Jf <br /> Print Name / UA.) o Ll t Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: _ <br /> WORK PLAN DATED:— <br /> Application <br /> Application Accepted By � Date Issued / / (,t Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R 'D PY DAT5 PERMIT/SERVICE REQUEST# INVOICE <br /> 3.5-0 g1 ,0 p GO p — <br /> C-57 WC -WAIVER C-57 Letter of Auth Iza io sign permit Encroachment doc 9/27/00 <br />