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FILE COPY <br /> WEAPPERMIT APPLICATION ARM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 �Onn <br /> (209) 468-3449 F l�0 (ZOttJ <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 /> Assessor's <br /> WELL Location-2-3&69 S, Sa nil r--e- PA Cross Street City R\Verloanzip 95367 Parcel#-2-4q-010-t-23_ <br /> PROPERTY Owner 1-SNA JcnCyvin C:�dress 1%3 - F• City.S�rOc,kt-�'A zJp'9S205'hone#j1J4)4G?-.I"7 <br /> C-57 Contractor Gceae 17r �Atldress gSrO l`lov.+e �a Ciry HArfi.leZ Zip9 Lic#48rIG5'Phone#-( 2N 313-5$00 <br /> Consultant/Sub Contractor S&COs- 2eAer"`t-'crAdress 307 V-;154r-aa,Sle. 103 CityjL?A \Cu- 41c# 6102 Phone#L`�tkle—C(-cu100 <br /> GIS Coordinates:X .Y .Township sovi-h Range at la-QS t Section 2q <br /> WORK TO BE PERFORMED: <br /> )IEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> $,`SOIL BORING# CP-I-- 3 0 OVER-BORE <br /> 0 WELL# n PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE It MULTIPLE CASINGS?fl YES ONO WELL CASING OIA: <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL n PVC n OTHER: <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL 43-1 TREMIE TYPE TO BE USED: 0 AUGERS 'HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: $Yes p No(N� : MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,.SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 6S' n 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signedx 7(Q+Fa A+ Tltle/Company S16-COP- -tf.-ierNA -IOnq ane <br /> Print Name aff A-yO,*eP10f�ie Date ( 3 DI <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> O� Z3S6 I v � YCW <br /> WORK PLAN DATED: I O <br /> Application Accepted By Date Issued WLArea & <br /> s .�...,.�..�.� <br /> Grout Inspection By Date Final Inspection By Date 4� <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUCHECK# 'D BY DA PERMIT/SERVICE REQUEST 9 INVOICE <br /> 3501 $ NT REMnTED o0 2 6! <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to An permit_Encroachment doc) 9/27/00 <br /> IPA.- <br /> EO <br /> A£0 39Vd aOO-U H13I3 ££4£894602 T£ :6T 000Z/V0/ZT <br />