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F COPY <br /> WEL•PERMITAPP'LICATIONRM �� E <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 n <br /> (209) 468-3449 R�- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED vvvv���, ���1 1 <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 Tille,Chapter 9-1115.3 and the Standards Of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL LocationZ3ks .S, Sa niQ EC IZO Assessor's <br /> T cross street city 1'G\VOT�r1 kZiP gS367 Parcel# 7 Ljgro7O- it) <br /> PROPERTY Owner_ 1 roy Roe Address2'S 665 Scvi"li. laity R�J�r�1Ak Zip gS367 Phone# �� $6y-7,69: <br /> C-57 Contractor-&?�¢95= ,�r r li nth Address q iSo j4owe p cl CityNarti 7.e2 Zip94S'53 Lic#LIW6SPhone$(4 -;m SQa <br /> Consultant/Sub Contractor SaCOP- 1'n'I­ernn*iuvrl Address 3017 Ki 6.'f Ad,S+e IOOCiry Ru nCka LO�"tr(c# OZ Phone# 9l L8J6I-d4OD <br /> GIS Coordinates:X ,Y ,Township 3 S Range G C Section Z 7 <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL/BORING(CPT.GEOPROSE,HYDROPUNCH..//HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> "OSOIL BORING# CPT--1 D OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Zrr MULTIPLE CASINGS?0 YES ONO W ELL CASING DIA: <br /> D EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6s, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: flYes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER:_O OTHER APPROX.BORING DEPTH 1�15� D BOLTED 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinancesand Regulations, and all applicable California State Laws. <br /> Signedx jnn 71tle/Companyyxi�loc- Geol c"Stts1=CoR Sn'�nat10Aa( ''bA <br /> Print Name J ctT//'''� 4yCl-+er (011e Date <br /> DEPARTIV.2-1/ <br /> gMENT USE ONLY p <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2356 / / <br /> WORKPLAN DATED: AI'IW O <br /> Application Accepted By Date Issued Area l/ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECKS' RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57_ WC---WAIVER C-57 Letter of Authorization to sign Ormit—Encroachment doc_. - 9/27/00 <br /> 60 39Cd 600-U HIAId ££4E89t,60L TEIET 000Z/U0/LT <br />