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r(n).iP)y( <br /> SWELL PERMIT APPLICATION FORM SITE <br /> _► �' ' .r .�11,�1 MITIGATION <br /> N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �, A���' NVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 02 `�� 304 E. Weber, Third Floor, Stockton, CA., 95202 ��" <br /> (209) 468-3449 Dir - Q� <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 /> Sant a Rd Cross Street city p 3(3 ar el# Is <br /> WELL Location Z3 S65 R iyeA'NA k- Z, q5 Parcel# <br /> OwnerPROPERTYDpIN POI n�—j 0_ —Address 23 "T � <br /> S .%On Ee ,ty {Z%wrb6A&V-Zip 4SS67 Phone# Zo9)83 8-7SCL% <br /> 7' <br /> C-5Contractor V A-w Dry 11 i ddress PO 90)e - City.Tsl-exon Zipq-T641 Licoi� q—bq Phone#1Qj6�Z71-4rvv <br /> gnC1.b <br /> Consultant ISub CoucoO-Z Phone# "9(6)e61-0LfDd& o+ 1 ? Ki .bS� �D <br /> Ll <br /> GIS Coordinates X 'Y ,Township 3 -�--0 h Range 1 S t Section 2 <br /> WORK TO BI=PERFORMED. <br /> `"EW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION(choose type below) <br /> []SOIL BOpImr.4 []OVER-BORE <br /> WELL#-S�-1 �"2Z 5"23 Q PRESSURE GROUT <br /> "Other + f Grout Specifications <br /> COMMENTS <br /> TYPE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1]MONITORING �FIOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?[]YES VNO WELL CASING DIA I <br /> 1]EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING []STEEL ';PVC p OTHER <br /> OOR MUD ROTARY DEPTH OF GROUT SEAL--3-1 TREMIE TYPE TO BE USED AUGERS ,HOSE <br /> SPARGE p PUSH POINT GROUT SEAL PUMPED )'Yes [I No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER []OTHER APPROX BORING DEPTH 3$ -_) BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED' t-a (if YES,Inst 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 INSPECTION& <br /> hereby certify that 1 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 /> Signed '`+ Title/Company <br /> Print Name R riail Gare ~ S�-afi� G eb lo9 1S"­ Date (( oZ <br /> DEPARTMENT USE ONLY <br /> 49 SITE MAP IN UNIT IV FILE, ADDRESS: �'5�� f s' � <br /> WORK PLAN DATED: MACY 7— 2-o0'Z- - OgA VL / <br /> Application Accepted By Date Issued a r iD 7-- Areay7/ <br /> Grout Inspection By.r Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> MENTS/CONDITIONS <br /> P <br /> OUNTING ONLY AID# Ferx <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l ?�Z a / SR# 301.E <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permitt d � 9/27/00 <br />