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FILE C <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 vn C Pis <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> >pplication 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 I25Z N STAu/SL�4u5 S7RL17' Cross Street ,4v/eaRA City .SToGACroN Zip Parcel# <br /> PROPERTY Owner C4uF0,¢N/A STA1L OF Address TAY 6»»GDtRJ SNoQ� City lave �fA< zipPhone# <br /> Th ��ft� 9 �oCue cit 0#.A6,,et Z; 9'(553 Lc#33082'none# 9z5 313 SFoo <br /> C-57 Contractor C,' t Address Y p <br /> Consultant/Sub Contractor41AAD44 f 2771 /l H.lVC.Address/f!f )-Ig4 L' +cKTa�Lic# Phone#,10`x-1S9-OS/Y <br /> SurrL S <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING# 5 CAT/n,etcr 1&V &19S 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> "Other: Grout Specifications: /VL�4TG�GuLnl7� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE eZ t I MULTIPLE CASINGS?0 YES ANO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Q/A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY _ DFPTH OF GROUT SEAL_�Y�_TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE -F0'PUSH ��-�� GROUT SEAL PUMPED: ` fes p No (NOTE. MAXIMUM FREE-FALL DEPTH IS 30') <br /> / Amu �. .-t <br /> SOIL BORING �� 0 HAND AUGER GROUT SPECIFICATIONS: /Ir 'A i a.r.+.�W i <br /> 0 OTHER: ) OTHERnivcrr Push APPROX.BORING DEPTH /00 PLG•T 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? Al (if YES,list specifications here): <br /> 'COMMENTS: S/rf, 1,A/dLST/6A710A) CPr 2/24cr PUSH PA1;Z5 Aop— --AvuivDiOATE2 -5,444PUS <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 Re ations, and all pplicable California State Laws.. <br /> %Signed x (/ Title/Company (i�.vOb.? C.� _r, / tDG�Sf�ta°��/ES . <br /> Print Name r <br /> d Int Date_21/. l 1,/ <br /> ��r----— <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: i-252 JJ- <br /> WORK <br /> J WORK PLAN DATED: 23 Cca1 --XrJ-3 AIZZ�'3''s!%�—Z of Date Issued / Area <br /> Application Accepted By IL <br /> Grout Inspection By <br /> Date Final Inspection By Date___ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501! �j9 8 $D $ C'.vrfZ 3 zs 03 0 3 330 <br /> 9/27/00 <br /> 2- <br /> C-57 f WC -WAIVER C-57 Letter of Authorization to sign permit v' Encroachment doc NA <br />