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leFILE COPY <br /> WELPPERMIT APPLICATION FORM SITE <br /> SAN MITIGATION <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> :57 <br /> (03 U/ L� (209) 468-3449 Q� WS <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z/SE <br /> Application is her y made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County <br /> nevelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> �O701 IN.: CLCUXAb /Q c Assessors <br /> WELL Location � ross Street ity TocsTcv✓'Zip Parcel# <br /> ddressl _ feunw zp 95zozPhone#PROPERTY Owner� ANiu9. 97�- G349 <br /> ,_. <br /> C-57 Contractor CdfEKd Address Re•QOX /zZ� - -City eF°t Zip f V-173Lic#177661 Phone#-707'.SW? .3 -77- <br /> Consultant/ <br /> LConsultant/Sub Contractor Lf(L Address/9/b �Wftr-Ir/Ir'uFl CiryetELic# _Phone#`T/d '>T -7'/ '/ <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> _%QjQEW WELL/BORING((;PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING#_ 0 OVER-BORE <br /> WELL# Hw- 21Y� aPRESSURE GROUT <br /> -Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS °'fir//�•'�� <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASIl ONO WELL CASING DIA: Y�v <br /> D EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS 5-CM Syo TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR ")IrFtUO ROTARY DEPTH OF GROUT SEAL O—/ZO TREMIE TYPE TO BE USED 0 AUGERS _,a61OSE/,19PF <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:lyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS. 647 /Almlt <br /> p OTHER:_O OTHER APPROX.BORING DEPTH­/ZD ' .L@OLTEO TRAFFIC BOX or 0 STOVE PIPE r <br /> CONDUCTOR CASING PROPO D? V61 (if YES,lists ificvIi ns here): a eir r'°e.OVL7� 9°r <br /> 1 r <br /> "COMMENTS: 166 gu U OW <br /> NOTE: OFFSITE I§ORINGS 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 County Ordinances, <br /> Rules and Regulations,and all applicable <br /> /C%�Jlforni State Laws. /J <br /> Signed x el Title/Company <br /> Print Name 2i LA/ r/. �`d r7 Date 41G�0/ <br /> DEPARTMENT USE <br /> ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: It <br /> If G/�'VY /"r, "- �2W G' C/3 <br /> WORK PLAN DATED: ' 2, & <br /> 'g <br /> Application Accepted By Date Issued `� / -Area <br /> Date Final Inspection B ------Date--�"`r' �ZI <br /> Grout Inspection By PecU Y <br /> Destruction inspection By Date <br /> COMMENTS/CONDITIONS: C <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> D �iGk/ 3I56-/( SR# 11426 63 <br /> L-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />