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MAPA <br /> WELL' �'ERMIT APPLICATION ARM SITE <br /> MITIGATION <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> FE� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> � <br /> �C 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> u u IE��ED (209) 468-3449 <br /> MAR 0 8 ���� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is here de to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> 6 �+ u ;Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> DDrr �1ialL/I�IJp1 /�}}�(II/T e��� /�, Assessors <br /> WE€Q u� a(4grOlf rY_ ye KL r Cross Street 67CM4'(!7 _City.SfaYTaJ Zip XYZ Parcel# I -7S <br /> PROPERTY Owner •) SFS"1/ �,fi�E Address466S�/ITI�RMU DIIL CityJ70(X7pU Zipfg2jq Phone# `//3'�SS2>✓ <br /> C-57 Contractor MIT u'-2/ >.II!J1 VS [Ad'd�ress S3G0 S. WATT AJ,I'A. CCpilt�yFhg NVF 1Te ZipfSL24 Lic#44&7 Phone# '/ 1Q-30? <br /> Consultant/Sub ContractorAL✓A1J[{;D QptVA�L4ddress 737 S#WJ a. City�� R�Uc#AWPhone# T47-��0 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: - <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �I" <br /> MONITORING ' LHOLLOW STEM DIA.OF BOREHOLE �'Z MULTIPLE CASINGS?]]YES XNO W ELL CASING DIA:42 <br /> ,EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�J.11 SO TYPEOFCASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL V'AR& TREMIE TYPE TO BE USED: 9AUGERS 0 HOSE <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes )0o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �)' eILR�W TY��N CGMff�T <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH�br'3S7 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> n CONDUCTOR CASING PROPOSED? if YES,list specifications here): <br /> 'COMMENTS: Z - 7 ,/ �1WlAVl)GI�Q'I�E� �G�)F.K.LPACI�lIJAC VIGS 3 L1� 1/t•1017OLI VyELLS <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(py� ces, Rule and Regulations, and all applicable California State Laws. / <br /> Signed x -I� �• Title/Company Ff L7 � A6,r- <br /> PrintName TF1I.=L R- •�� _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By �• ` Date Issued 2L/ Area <br /> Grout Inspection By Date Final Inspection ByDate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> PE CODESTFEEINFO <br /> I <br /> 3v( eco V 3 1, <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho 'z t sign p rmit_Encroachment doc_ 9/27/00 <br />