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WEL"ERMIT APPLICATION! SRM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 D rF C� <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 /> �}D Assesspe, <br /> WELL Location �� _. _ �Cross/�S�tr1ee 11M,, ( ity �p-1QQ -1 .Parcel# _ <br /> PROPERTY Ownerffi. Addd�drress1�l��,-1 ,,'CQQU4//Lt City Zipl_�MPhon <br /> C-57 Contractor Address C /lam C Zip _LicPhone#fts-X135-8-pq, <br /> c /�,� fiLA�KS�4 p <br /> Consultant/Sub ContractorJ � Address 301( Ug&rq I �►IAf� City Cnerlo Lic# sq 8 Phone# 1 1(o <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# 0 OVER-BORE <br /> WELL#AW 12, midk3 (K I j 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r, <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE rr MULTIPLE CASINGS? YES A10 WELL CASING DIA: <br /> 0 EXTRACTION P[n]'A_1rV HAMMERIDRIVEN CASING THICKNESSTYPE OF CASING: []STEEL XPVC []OTHER: <br /> 0 VAPOR [l MUD ROTARY DEPTH OF GROUT SEAL {`>�' Iter TREMIE TYPE TO BE USED: []AUGERS HOSE <br /> []AIR SPARGE p PUSH POINT GROUT SEAL PUMPED:jM<es p No (NOTE": ,MAXIMUM FREE-FALL DEPTH 11130') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:_ 2.W� CPYy.A <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 46( _*0LTED TRAFFIC BOX or 0 STOVE PIPE <br /> 1 , ((�CONDUCTOR CASING PROPOSED? NO (if YES,list specifications here): <br /> *COMMENTS: �ee A62,o ) �o�_ P.ggSg>' kc <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company pr,- (n sy-CupZ <br /> Print Name .S Date d b <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 <br /> WORK PLAN DATED: -00 Z - -OCA o <br /> Application Accepted By Date Issued ��/ —b� Area � <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES IFEEINFO AMOUNT REMFTTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> o 2z 3Z 3 i9Is R# 2.; �_5 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> 60 39Vd 10013 H13Id CEPE89VGOZ TE:ET 0002/t,0/7,Z <br />