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WELSERMIT APPLICATION FAM SITE <br /> r ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FILE COPY <br /> (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 /> WELL Location 901 YJ- S1401-TCross Street a4rrI � Assessors <br /> Parcel# 09?"11-79 <br /> /o Sir,4S P20R ��• 2 `1 S— a 95zo4`Phone# 209 *8-9Aoo <br /> PROPERTY Owner 4o SIMS G2JfJ M(sr Address 7�'l LlrJcet.rJ rrtcity toGtLTe Zip <br /> C-57 Contractor QLILGG It.-StTJ Address 9570 {•,o411L Re AD City HHlrr,-if. ip9`1533Lic# 165Phone# 9R5 313-5800 <br /> Consultant/Sub ContractorLF2 L4�t.tt-lr atcKL.Address 1900 PO-KLI- ST. CityrALtJruiic# N A Phone# 510 (5:k-�5ct0 <br /> GIS Coordinates:X610 9 (' ,Y 215 l q 13 ,Township 2 Range 6 Section :71 1 <br /> WORK TO BE PERFORMED: <br /> D NEW WELL I BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION (choose type below) <br /> )(SOIL BORING# 6�1 G3o2.•.1GS) 0 OVER-BORE <br /> D WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1•;5" MULTIPLE CASINGS?D YES 0 NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL CO' TREMIE TYPE TO BE USED: 0 AUGERS •HOSE/P,P <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: 1,Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 'SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: rifAT GS,MLrJT�QL.Jr0..1 r'r£ <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH--60-f--0 BOLTED TRAFFIC BOX or D 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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin les and Regulations, and all applicable California State Laws. <br /> Signed z �� W•�-,�\' Fo(L 170a S ILADStAA3 Title/Company S1-tT P2o'7. M!2 /L-;7(L L£J taL- G2r cttL. <br /> Print Name PLTL(L.. I.�Lt 1.t(L. Date 6/151/0) <br /> DEPARTMENT USE O/N—LY' <br /> SITE MAP IN UNIT IV FILE, ADDRESS: I <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 40 -Area F3 <br /> Grout Inspection By Date Final Inspection By Date <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/SERVICE REQUEST# INVOICE <br /> Z90 1 8 2� <br /> C-57 WC_WAIVER_ C-57 Letter of Authorization to sign permit_ ncroachment dock 9/27/00 <br />