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�y�- WELIWERMIT APPLICATION FOM SITE <br /> �V ly' MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> LJ� V ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �'�� COPY(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 <br /> WELL Location goo t^I. 8 3Pr�lra Fool-Y Cross Street G`LTT�SSJ2Crcity SToc-ym-,3 Zip95�.04 Parcel#-0ca-19 �3 <br /> Ltr1C°Lwt prtcP• LTo. �1 LtrlGo�rJ CM. Cit SToctLTo� Zi SA07 Phone#�.09-d�8.9Aoo <br /> PROPERTY Owner��^ SIMS&&OM M6 • Address TJ7-I y p� <br /> C-57 Contractor 62LGc 1^4'SITO Address 95o %AoaL ac,. CityMA2Tv1bIIip 99553Lic#�e$16.$ Phone#9?.5313-Sgoo <br /> Consultant/Sub Contractor LFrL LiJ nJL-F2%r-34 .Address 1500 P0aIL-L ST CityJ%u Lic# OJA Phone# 'Jlo 659-`I-'�60 <br /> GIS Coordinates:X 63-Z`I H3q ,Y ,Township '2, Range 6 Section ) <br /> WORK TO BE PERFORMED: DESTRUCTION choose type below) <br /> a NEW WELL/BORING(Uv T,GEOPROBE, HYDRO _NCH HAND-AUGER,OTHER`) <br /> ,SOIL BORING# C�25i R6g 5 Qo2,,.tGS� a OVER <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE 1,75" MULTIPLE CASINGS?a YES ONO WELL CASING DIA:_ <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 60 TREMIE TYPE TO BE USED: a AUGERS POSF{AP: <br /> a AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: -Wes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: OLAT GLME,.1" ZBE4—io, ,,L <br /> a OTHER:_O OTHER APPROX.BORING DEPTH (i0-, 0 BOLTED TRAFFIC BOX or a 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 les and Regulations, and all applicable California State Laws. <br /> Sign e-a =V Fol po., BfLADSAA�Title/Company 51 i L P&-0:1. P'l617- /�F-12. Lw"A -�21 cy-f- <br /> Print Name <br /> P�-L2 t�Ll�t2 _Date 6115/ol <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: fe CB <br /> WORK PLAN DATED: 'O <br /> Date Issued �0 Area O� <br /> Application Accepted By _>r9>� <br /> Grout Inspection By Date Final Inspection B9— -- Date <br /> Z <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />