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WELL ERMIT APPLICATION FC <br /> SITE <br /> OCT 24 2003MITIGATION <br /> 3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMEfff HEALTH ENVIRONMENTAL HEALTH DIVISION (PHS-EMD} UNIT 11I <br /> PERMIT/SERVICES 304 E.Weber, Third Floor, Stockton, CA,, 95202 <br /> (209) 4683449 <br /> NDN-REFUNDABLE PERMIT EXPIRES'I YEAR FROM DATE ISSUED <br /> 3ppllcation 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 Tine,Chapter 8-1115.3 and the Standards of Sari Joaquin County Public Health Services,Environmental Health Division. <br /> aa :r .. <br /> NELL Location J�g p � �: Cross Street._S Q�� � City _Zip �s31� Parcel#Zs S O <br /> 5y Vic,., Zip' S 3")phone#. <br /> PROPERTY Owner � Address 3^120 �,",1,L: � Cit Tc <br /> -� c 9-1 <br /> C-57 Contralto t Address.�O 13 ��b City sl�}a. zip��°'E} Lic#'1Z 04) Phanelf <br /> ortsulta l5ub +tastor�`�-e,�1� '�c�Q '�e�� Cz[ddress -SCiPhone#109 5-21t4119 <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BF PERFORMED. <br /> NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,-OTHER-) [I DESTRUCTION(choose type below) <br /> U SOIL BORING# 0 OVER-BORE <br /> WELL# 1mv 1 S f1 PRESSURE GROUT <br /> Other. Grout S clfcaflons; <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS S� \1\]i\3 <br /> 4MONITORING A HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?p YES a NO WELL CASING DIA: <br /> — <br /> a EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPE 05 CASING: D STEEL p PVC. D OTHER: <br /> i1 VAPOR .0 MUD ROTARY DEPTH OF GROUT SEAL—­ TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> p AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-T=ALL DEPTH IS 301 <br /> 0 SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: <br /> () -T <br /> O7HE=R: 0 OTHER APPRCX.BOR;NG DEPTH. j]BOLTED TRAFmc BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSE[]? (If YES,list specifications here). <br /> `COMMENTS: <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT Ill INSPECTOR 48 WORKING.HQURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> L <br /> I hereby certify that I have prepared this application and that the work will beHdiordance with San Joa <br /> County Ordinan` ul s 0ulations, and all applicable California StaSigned x ' TklelCampany Print Name ��el <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 4- g:. 1,LO,3, (,e,,�pn <br /> i <br /> Application Accepted By .�- e-� Date Issued .1 C, 7,3 D Area 6 z g <br /> Grout inspection By, ' Date Final Inspection By ��r(nnn�firl _Date Z3 O y <br /> Destruction Inspection By Date <br /> COMMENTS!CONDR IONS: <br /> .} Y <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE" PERMIT I SERVICE REQUEST# INVOICE <br /> ?�S C7 I+r 415 l 5�. I t2- oR9 3 S $D 7- i <br /> G-57__ WC i It -WAIVER__ C-57 Letter of Authorization to sign permit—Encroachment doc 9/27/00 <br /> ES �Jdd.'i 1010-1-� H12Id . 95 :Ej L0e3 <br /> /SZ/Zb :I l <br />