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1 <br /> WELL PERMIT APPLICATION FOM SITE <br /> FEB 1 9 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> cavi <br /> FI�EV��ONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> Ei�11TjSERVICES.;;arlEr 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 'M (209) 468-3449 <br /> t•.w-N1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> plication is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> L\n WX, S�wmn - 4"(n�i Assessors <br /> BLL Location �1'-"- Cross Street V� ty `���^ Zip GS7.dU Parcel# 137--56-I q <br /> tOPERTY Owner��-JM)Lty^ l0f�n7`"Y"'6'1 AW'-Address C-`k'j k%"X City Sbo<.21'J`. Zip ZDt Phcne# <br /> 57Contractorcj6d3a` G�''t``t"r^ Addressl$3511")v,a Qom'`" CityS4„Joln Zip 45LIKLici✓1-1u04ti%%Phone#4D%-2'3c,- Baa' <br /> /� SLA)x 216 7�' n <br /> )nsultant/Sub Contractor Clc,Aoa Gma Senl'Iba Addresslo`l� roll Clnl'/r P-k-VjCity4l(0,. 1­1c# '- Phone#9ZS4T6-21669 <br /> S Coordinates:X 31c.�)r C(w ,Y I'-lo Il I "; v.1 .Township ) Range DoE Section 10 <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> d WELL# M W-1-1 0 PRESSURE GROUT <br /> ether: GROUT SPECIFICATION <br /> OMMENTS: <br /> fPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLE (e t' MULTIPLE CASINGS?O YES 8 NO WELL CASING DIA:Z11 <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSOWJ AD TYPE OF CASING: 0 STEEL 9 PVC 0 OTHER: <br /> VAPOR o MUD ROTARY DEPTH OF GROUT SEAL 6-101 TREMIE TYPE TO BE USED: GAUGERS OHOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes9 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATION wa V1 4�Q <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 2S' G BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? 110 (if YES,list specifications here): <br /> OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br /> ' CALL T UNIT l�'y/' INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> iignedx 7)` DA- 7tle/Company_PRp—Kj CnVrR'A"4�Gl �e"c-)�•nl <br /> 'riot Name t1Y4 Date 21 19103 <br /> SITE MAP IN UNIT IV FILEDDRESS /WORK PLAN DATED <br /> DEPARTMENT LY�IU7> <br /> .ppliption Accepted By <br /> a Issued f Area--6J <br /> ;rout Inspection By Ej��� Date Final Inspection By Date <br /> )estruc ion Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D B DATE PERMIT!SERVICE REQUEST# INVOICE <br /> o 2 3 g�D <br /> C-57_ WC/WAIVER_ C-57 Letter of Authoriza ion to ign permit_ Encroachment doc_ 7/17/00 <br />