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WELtl�ERMIT;APPLICATION F`(JRM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UN9IV, <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 co <br /> (209) 468-3449 ON ' W2) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `f Da)- I u <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 /> AsseX33 - Ave—, �,1�city � p 9sza-� Parc11S4 - lD- <br /> WELL Location c,C� I C Cross Street�P.�tl,�w;r'2 Ci /� Zi oo <br /> C(� Pjt,j �. Pa (ot5�- ty /I q? ti-\ Zi 940!5 Phone# gzs=o yz-q <br /> ppE��Owner U Q Address Ci p (flS-s <br /> C ContractorCit� �Zip1Jc# 4�Phone COWU <br /> Consultant l Sub Contractor Address cll�� \ [�1(�f�� CityzZC x. Lic#65"y08 Phone# %�—&'^ OC) <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: /N•5/T C) Z314-5 ..0 <br /> []NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(choose type below) <br /> []SOIL BORING# V [I OVER-BORE <br /> V'INELL# 011-13— 'ARESSURE GROUT <br /> 'Other: — Grout Spe ifira6ons: <br /> COMMENTS: OQ_kE nc �c r "�At�aS�.{`� C�.rr. c� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING p HOLL W STEM DIA.OF BOREHOLE 1t",jn MULTIPLE CASINGS?0 YES �' O WELL CASING DIA: j0 <br /> [J EXTRACTION Q1.RPUH <br /> ERIDRIVEN CASING THICKNESS` TYPE OF CASING: T1=EL PVC OTHER: <br /> 0 VAPOR pARY DEPTH OF GROUT SEAL�f fllCdtp,J�3 TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> [I AIR SPARGE Q NT GROUT SEAL PUMPED: 0 Yes Q No (NOTE: MAXIMUM FREE-FA L DEPTH IS 301 <br /> ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: P ( r"b, <br /> a THER:i� `(`a OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or 0 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 /> R <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules nd Regulations, and all applicable CaliforniaStateLaws. <br /> Signed Title/Companyh'`75�S�r�!/1i� Sltia,� <br /> Print Name Date \��a <br /> /DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: !/' Z D U — /2• / ¢ <br /> Application Accepted 8y Date Issued��J/ Area J <br /> Grout Inspection B Date Final Inspection By <br /> Destruction Inspection By Date <br /> Xr <br /> COMMENTS ICON DITIONS: <br /> ` <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CFIECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 Z' �/ 60.C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> 60 EJdd 2100-1d HIAId EE17E89b60Z I6 :ET 0002/ti0/ZT <br />