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WELARMIT APPLICATION FAM <br /> SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Fioor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 <br /> Health Division. <br /> rs <br /> WELL Location ? y7 N �✓tSfi (6 • Cross Street In'v�� S /, City � <br /> 5�. Kje74 Zipf.4 .�Oj Parcel# ICJ - 3V0-Iy <br /> G/Uf"t'v!c`�""•' L4, - Su.rl2eme� Zip`��IS.y3 Phone# `/�'S=$HJ-9F,S-� <br /> PROPERTY Owner(�l�t✓ . t7� )c• fi 6�3�''•* <br /> i Address &Ve7l �j)tH�t� C•✓�d Ciry <br /> C-57 Contractor Cunt• )c ✓J�I ))in,n Address 3G IOMCc Gn�t City ..�.L,�G,� Zip`5]` Lic#717i! Phone#9/f�-/� 38-ilG-� <br /> /Qu"j, <br /> Consultant l Sub Contractor 5 `cC7� Address 3o/V )��1� :,-G if-lo62 City G��.:(nva Lic# Phone# 'Ilk <br /> GIS Coordinates:X <br /> Y.,TownshipRange Section <br /> WORK TO BE PERFORMED: - XDESTRUCTION(choose type below) <br /> U NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') B.OVER-BORE <br /> p SOIL BORING# 'PPRESSURE GROUT <br /> a WELL ft ��,+4.•n.7 <br /> lions: <br /> 'Other: Grout Speciflca ✓I2«'/" <br /> COMMENTS: , 2c r , ✓ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING O HOLLOW STEM DIA.OF BOREHOLE__MULTIPLE CASINGS?BYES flNO WELL CASING DIA:0" <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sr h (J TYPE OF CASING STEEL ff PVC D OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 4W TREMIE TYPE TO BE USED: it AUGERS fl HOSE <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: JgYes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> HAND AUGER GROUT SPECIFICATIONS: IVZ,;'I c °"'c'n fi <br /> 1]SOIL BORING O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> �OTHER:_0 OTHER APPROX.BORING DEPTH__&O-� Q <br /> CONDUCTOR CASING PROPOSED? it/ (if YES,lis//t specifications here): <br /> 'COMMENTS: M w 1 M v/ M w 3 w I ) he de";S f c V E'r�f, <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 /> 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 /> ,D <br /> Title/Company i c69/ '1 j <br /> Signed x <br /> Date <br /> Print Name c1, ✓!! <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: i <br /> WORK PIAN DATED: <br /> Date Issued J /7 -Z" Area <br /> Application Accepted By Date <br /> Grout Inspection By Date, Li a z Final Inspection By <br /> c <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> RPECODES <br /> NG ONLY: AID# cern <br /> FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> J�Zy�IZ ��L SR# a' <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ 9/27/00 <br />