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WELePERMIT APPLICATION 'ORli�ii <br /> 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 <br /> (209) 468-3449 b , <br /> NON-REFUNDABLE PERMIT EXPIRES'I 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 /> 1 _�� P J� 1 q Assessor's <br /> WELL Location (o LLCTI-\L }�V�}� CrossStreetj1 i city EXE. Zip I�Zb Parcel#(�} '� [(� 6 <br /> PROPERTY Owner Cir,eU on iibduc lr, Address �c�_ CityUplaA zipPhone# <br /> C-57 Contractor_ Address v/y1 Ci �ip[.,�,�17J�Lic j 1 Phone 47Z5.3I�X 80 <br /> Consultant/Sub Contractor Address ��� 'yL{)City i2lel c#(;1008 Phone# I� -&j-0g0D <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: t a <br /> EW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# <br /> 1]OVER-BORE <br /> WELL#810$ fI1W�,PflWipir•M1ukM <br /> 'Other —T— 0 PRESSURE GROUT <br /> Grout Specifications: Qp <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING %-1011OLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YESNO WELL CASING DIA: Z <br /> D EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS SING:TYPE OF CAll STEEL /ycy'�PVC []OTHER: <br /> 0 VAPOR H MUD ROTARY DEPTH OF GROUT SEA e 0-16� R�- TREMIE TYPE TO BE USED: I7 AUGERS HOSE <br /> p AIR SPARGE p PUSH POINT .GROUT SEAL PUMPED: )gYes '1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:- E4 <br /> []OTHER-._a OTHER APPROX.BORING DEPTH3e [g, EIOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> \\ CONDUCTOR CASING PROPOSED?�Le' omme,.4s(ifYES,IistspeciFcations here): <br /> 'COMMENTS: A C'cn61CJ �rz Cea n� �i�� G�'ve�v.te ko .n"jp•�E 1� A Q ymo kv�, <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 Ordi nc es and Regulations, and all applicable California State Laws.e <br /> Signed x /' Title/Company ; ate"t �veAk <br /> Print Name Zt -.c}tJ �SLP, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 6te33 <br /> WORK PLAN DATED: -►el—pV <br /> Application Accepted By Date Issued 3 �� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> vt <br /> ;ki <br /> AID# <br /> AMOUNT REMITTED CHECiK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2 zs 3-5 SR# OD25 ,5� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc„_ 9/27/00 <br /> CO 39Vd J00-d HJ_dId CEVE89PSOE TE :ET 0002/t�0/Zl <br />