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r. <br /> FILE C��Y <br /> WELLIERMIT qPoCATION FAM 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 1 r fin( <br /> (209) 468-3449 1/ <br /> NON-REFUNDABLE PER 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 <br /> ism ade in al Health compliance <br /> with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Health Di <br /> WELL Location 75 West VatR'co Roue cross screetS,T Ivd clty <br /> Zlp 5376 Parcekk X6-130 '09 <br /> PROPERTY Owner I <br /> COA,.5'0w0'4TSd CN'NR• Address TS W VALP'C0 City 1 ,r.,l Zip�h 376 Phane#�1(A�`•Z�l-`�`/JD <br /> C-57 Contractor VirClneX Address .,2110 AbkrI5 AveCity San Lv'dro Zip 9Y577Lic# 70S917Phoneu (.2LO 569-7674 <br /> ,t ' Dona,° 715508 Phone# 41 93f-9450 <br /> Consultant/Sub Contractor �cton-M'rkelSWr AddressSO49 RZ fYlaif7vasc 1�14+IY City Ntus Lic# ¢J <br /> GIS Coordinates:XIAT 1 37.71 0614'i ,Ylrmh; -12�, L`(Z58`�Y ,Tomship <br /> (�u2 S Range OS Section .3 3 <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> EW W ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D OVER-BORE <br /> ^SOIL BORING#, y, 'r0ol } g PRESSURE GROUT <br /> p WELL# n Ne <br /> Grout Specifications: NPC4{ rolren{ <br /> *Other. <br /> COMMENTS: UC,- 1-03 UV HPH U - HPS `JV - NP(o <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ���,� <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE /.7S" MULTIPLE CASINGS?U YES a NO WELL CASING DIA: <br /> U EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS IVA TYPE OF CASING: 11 STEEL a PVC p OTHER: A/OAIL- <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL taiul d.T4 TREMIE TYPE TO BE USED: a AUGERS AHOSE <br /> p AIR SPARGE JWUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: rltot C¢mC it BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> a OTHER: N OTHER APPROX.BORING DEPTH 50 <br /> CONDUCTOR CASING PROPOSED?--tjQ (K YES,list specifications here): <br /> - <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 /> 1 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 /> y � Title/Company Project Enoineer�Acton /�ickelson <br /> Signed x <br /> Date <br /> Print Name v1oe't- L ted. DEPARTMENT USE O LY <br /> SITE MAP IN UNIT IVFILE,ADD-SS: 3 <br /> WORK PLAN DATED: � p <br /> Date Issued 2�� 03 Area ISO <br /> Application Accepted By Date <br /> Grout Inspection By <br /> Date Final Inspection By <br /> Destruction Inspection By Date _ <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY D PERMIT I SERVICE REQUEST# INVOICE <br /> RR# 3 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />