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WELL . ERMIT APPLICATION FL - .M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 4 atNYANMENTAL HEALTH DIVISION (PHS-EHD) <br /> �40�yFE8 304WE.�Weber, Third Floor, Stockton, CA., 95202 <br /> SAN �pIR�µMEN p Epi (209) 468-3449 <br /> NY RSH E �H pEP NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby I&A 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 /> Assessors <br /> WELL Location 1-;324 S. V., Alfie- Cross Street E. 9%sl ka R.1� City L sc�/a h Zip 45320 Parcel# Lo S OqO ZS <br /> PROPERTYOwner R4ev+ Address 11+323 S. V4, City ESc,(o. Zip`K�Phone# �_'�`{�tj <br /> C-57 Contractor risco Address 349 5Le✓l s art Cityv.,Ilex S Zip 15ZSZ Lic#h3f(15 Phone#7001.172P976 <br /> Consultant/Sub Contractor/ATG Address 1 114 t k( City_12jejo Lic# Phone#"-S3S-?Z21 <br /> GIS Coordinates:X 'Y Township T - S Range q a Section 3-5 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, EOPROB YDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type belcW) " <br /> �S BORING# 50:1 SR Z, Y3 73 t 0 OVER <br /> WELL# o PRESSURE GROUT <br /> 'Other: Grout Saecifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 MULTIPLE CASINGS?o YES )(NO WELL CASING DIANA <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS Ni4 TYPE OF CASING: o STEEL 0 PVC G OTHER: WA <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL -J,;Wo 40TREMIE TYPE TO BE USED: o AUGERS G HOSE <br /> a AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: Ns..+ <br /> o OTHER:_O OTHER APPROX.BORING DEPTH Ido 10'-. 4J Q BOLTED TRAFFIC BOX or STOVE PIPE <br /> 11 CONDUCTOR CASING PROPOSED? &0 (if YES,list specifications here): <br /> 'COMMENTS: C7ra ek-6 . -+,4o 4o w' , bne. 4s -so <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 Regulations, and all applicable California State Laws. l /1� A- <br /> Signed x / <br /> — -- Title/Company S-f �eoloQ;sl /t�� <br /> J�vh fr<���rrfi Date FaL II Zw< <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I �L 3 Z-l- V A ,.. AU n�- <br /> WORK PLAN DATED: It I t 5—, <br /> r <br /> Application Accepted By (d�;��C �- Date Issued 2, 1 D Area 2- <br /> Grout Inspection By 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 /> a-ckc $4s d b 4c( tGI S aS Z, <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />