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WELL PL-RMIT APPLICATION FOF %..:j SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UHIGINAL <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> )plication 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 /> )aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> y� ( Assess '— ' -b r <br /> ELL Locatlon� f�Q I i�,�C . Cross Street City Zi�_Parcel# <br /> 1OPERTYOwnerC 0L^K,c�, G! Addres C _ amity ���� C�Phone# _ 7 <br /> -57 Contra cto �,`( �` Ad`dresJs' City � Zipq�5 Lic�'_1Lr�u�DPhone# `J <br /> Q / <br /> onsultant/SubContractol2y ? Yf�O�\� -Z Address 61 l jawe.W416*k* "D City('JJ'r(lDV6tLic# Phone#(ql� t— <br /> IS Coordinates:X Y Township J Range Section <br /> 'ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> Il SOIL BORING# Q OVER-BORE <br /> ' /ELL Q PRESSURE GROUT <br /> lther: / Grout Specifications: <br /> OMMENTS: -eAreA [APrO�-P� — <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING %-A IOLLOW STEM DIA.OF BOREHOLE t MULTIPLE CASINGS?U YES O WELL CASING DIA: t :- <br /> EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESeQ' C) TYPE OF CASING: II STEEL )hVC O OTHER: <br /> VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL — TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: []Ye �lo (NOTE: MAXIMUM FREE-F L DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: 0 OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?. (if YES,list specifications here): <br /> :OMMENTS: <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 /> hereby certify that I ha repared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ord' es, _ and Regulations, and all applicable Californiia��Sta(t�e Laws. !cam <br /> igi�: Title/Company ��1C(, t""�l/( IJ, � �^J' <br /> ;int Name Date <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: 33 q <br /> IORK PLAN DATED: I D Z <br /> ,D <br /> `��_ Date Issued AreaA Z <br /> ,plication Accepted By J�/(o•(j3 <br /> rout Inspection By <br /> Date Final inspection Date <br /> estruction Inspection By Date <br /> OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUES7TV <br /> INVOICE <br /> X501 �- <br /> '-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />