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WELL ARMIT APPLICATION F&�Mj <br /> SITE <br /> 4 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 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ')plication is hereby made to San Joaquin County for a permit to construct andfor install the work described. This application is made in compliance with San <br /> aquin County Development Title,C apter 5-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> q� /^ 7,,n Assessor's <br /> ALL Location }' _ Cross Street �r ity 9 Zip _/ Parcel# <br /> tOPERTY Owner Address 46?2_? i7` e-' ip� ,Phone# <br /> _ 3117Y �l(2 4�t <br /> ° p 2LiC 7 y'x� 7Z7� <br /> 57 Contractor Address Ci Zi E hone# <br /> msultant/Sub Contractor-,A*( ' Address�/_ /mak'[ # Phone# `e7 <br /> S Coordinates:X Y Township Range Section <br /> jM TO BE PERFORMED: <br /> i VIEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> D SOIL BORING# ©OVER-BORE <br /> 0 WELL# p PRESSURE GROUT <br /> ther: Grout Specifications: <br /> )MMENTS: <br /> 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS � <br /> vIONITORING d HOLLOW STEM DIA,OF BOREHOLE -r167A BOREHOLE—r167MULTIPLE CASINGS?o YES R4O WELL CASING DIA:1--l?_� ' <br /> _XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL h'V�VC 1]OTHER: <br /> /APOR 11 MUD ROTARY DEPTH OF GROUT SEAL. 72t8�T— TREMIE TYPE TO BE USED: )I:Z�_UGERS 0 HOSE <br /> NIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes �No (NOT' f ,F,: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 30IL BORING a HAND AUGER GROUT SPECIFICATIONS: y{-CawL�L, <br /> JTHER: a OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDU.CTOR CASING PF OPOSED? (if YES,list specifications here): <br /> ! OMMENTS: (�lk �- ax <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> Hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> )Unty Ordinances, Rules and Regulations, and all applicable California State Law§. <br /> � <br /> lned x k{Ksud.p Title/Company 66 I" <br /> nt Name ` {q4A_ L12 5((�•-�st7 <br /> Date_ <br /> DEPARTMENT USE ONLY <br /> i TE MAP IN UNIT IV FILE, ADDRESS: <br /> I <br /> ORK PLAN DATED: OP6 oc ., .... '_ <br /> r <br /> Plication Accepted By W ate issued &7M Area <br /> gut Inspection By Date Final Inspection By Date <br /> struction Inspection By Date <br /> i _ <br /> 'i )MMENTS/CONDITIONS: <br /> .CCOUNTING ONLY: AIN <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# C' BY DAT PERMIT!SERVICE REQUEST# INVOICE <br /> 3fr3 � � 0 s <br /> i 62r <br /> 57 WC -WAIVER C-57 Letter of Auth i do t sign permit Encroachrnent doc 9/27/00 <br />