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CURY <br /> WE,4IERMIT APPLICATi©N ORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> oz juq 14 ENVIORMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 (0 �3 <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 descnbed 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 41-W-01-2- <br /> WELL Location 235-0 S, SaA-k r7e Ra Cross Street city %ft� �k ipgS _Parcel# � <br /> PROPER { O <br /> Owner Cir�.lt� 1l-J of� Address 667 afz=arre� S'� #� City.Sng�so�c3� z,p)410 Phone# ES1 yid~ �� <br /> C-67'Contractor �`^� �`���s r Address p,n, QoX 4 16 -- Ctvl!g i Oa Zip X64 Lic# 7—O-idPhone# 4 N) <br /> 100 f�4Rclw <br /> Consultant/Sub OontractorS��4R n` `'411141 Address 3537 Ki OHO repa,s _cityC br'&0 Lic# 102= Phone#01b <br /> GIS Coordinates Y .Township 3 S ou'irh Range CaSt__� _Section <br /> WgRK TO BE PEI]EORIII E <br /> ,"P-W WELL/BORWG'(CPT,GEOPFiOBE,HYDROPtJNCH,HAND-AUGER,OTHER*) []DESTRUCTION(choose type below) <br /> t]SOIL BORING# []OVER-BORE <br /> )(11VELL# PRESSURE GROUT <br /> *Other- %VCII AL - ro i, S ZO Arout Specifications <br /> COMMENTS <br /> JXPE OF WELL INSTALLATION TYPE ZONSTRUCTION SPECIFICATIONS R S--vel s 31y-4 el.ia, <br /> [I MONITORING HOLLOW STEM DIA OF BOREHOLE MU.TIPLE CASINGS11 YES XNO WELL CASING DIA <br /> TION Q AIR HAMMERIDRIVEN CASING THICKNESS Z-4,14o >TY> �E OF CASING []STEEL XPVC []OTHER <br /> -wet <br /> OR MUD ROTARY DEPTH OF GROUT SEAL- , TREMIE TYPE TO BE USED )'AUGERS HOSE <br /> SNRGE ©PUSH POINT GROUT SEAL PUMPED )gYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> t]SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> []OTHER_ �l OTHER APPROX BORING DEPTHvlo s e, ,�BOLTE=D TRAFFIC SOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED7-.j�_/0 (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 /> horeby certify that 1 have prepared this application and that the work will be done in accordance with San ,Joaquin <br /> County dinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed k5Lw Title/Company S e�raoR ,n 4+erna lana I �,�C, <br /> g.rr%a 6 C-A��— S f:SLf- G eblc9 ist- Date <br /> Print Name_ -- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV RILE,ADDRESS:_ z3s& L s' &!'�- 4 �or <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Data IssuedT <br /> Grout Inspection By. Date Final Inspection By Date - <br /> Destructlon Inspection By IV Date <br /> MENTSIGONDITIQNS, <br /> ACCOUNTING ONLY AID# Feru <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REOUEST# INVOICE <br /> C-57-11"' WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc � 9/27/00 <br />