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WE* PERMIT APP.LICATIONISCIRM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATIONUNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 r <br /> (209) 468-3449 6 <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 Health Division. <br /> L)j\W�h v+- Lay /� As <br /> rs <br /> �YWWEELL Location Cross Street lam` City. UYY Zi�GJr��Parcel# A 0) <br /> vuvT <br /> PROPERTY Owner D r`a'+.Y-�AddreS 6M <br /> Y� , IA.Ci tV 7 Pho eYy�'1M1` is ql <br /> C-57 Contracto Address D� C11• Ci ip /ryL`•pt�XA <br /> Consultant/Sub Contractor Addres 4' 4NkQ LA*4_ —PhonC W -6q6 <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFOR <br /> NEW WELL/BORIN (CPT, EOPROBE,HYDROPUN HHAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> OIL BORING# 0 OVER-BORE <br /> 01 n�W WELL# n PRESSURE GROUT <br /> 'OtherrO«�./ �N .Q? Grout Specifications: <br /> COMMENTS: VV\DLk <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO W ELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER: �OTHER_�L _ APPROX.BORING DEPTH _ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OEd <br /> 4mrices, Rule R Regulations, and all applicable California State Laws. <br /> Sign G Title/Company <br /> Print Name �.�5 Date <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /<2tI2 4// /U 45ry� <br /> WORK PLAN DATED:_�Y <br /> Application Accepted By _ ._ Date Issued ���/ Area <br /> / T <br /> Grout Inspection By r Date / C Fnal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUNT REMUTED CHECKS` RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o / I s91'5-1111' a513# 7-936 9 <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to sign permit / Encroachment doc_ 9/27/00 <br /> CO 39Cd 60013 H13Id £E4£89660Z TE :£T 000Z/b0/ZT <br />