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0FORIGI lWELL PERMIT APPLICATION CI 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 <br /> ,r ,'J ��], -a (209) 468-3449 JAN 1 6 2001 <br /> U <br /> C V (ZCZ 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 appli o�js�n�de iri Fo�nplialice with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Servicesn�iFgii gntal Health Di1.son. <br /> \ t t Assessor's <br /> 6 ���'� VU { ' Vuv Cross Street City Zip � � Parcel# 11-7 1�. --G3 <br /> WELL Location p_ 41 / _2�/ t J <br /> /_ `� gLf(� City�l � ✓1 Zip"i7ZP ) Phone# T <br /> PROPERTY Owner ( , 1 _ A <br /> N�S���✓l!�7— Address 323� J9 City ��G Zipic hone# <br /> C-57 Contractor CC ��pf_ ,, J/67 ��(� <br /> C C �fl /UO►� W _moi _ ic#bC�2L7 Phone# "G <br /> Consultant/Sub Contractor Address <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a OVER-BORE <br /> SOIL BORING# 0 PRESSURE GROUT <br /> `�'W ELL# <br /> gi <br /> 'Other: !!__ Grout Specification , <br /> COMMENTS: <br /> Zv !DS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> v1ONITORING �IOLLOW STEM DIA.OF BOREHOLE r I MULTIPLE <br /> OF SINGS?a DESTEp OD WELLPVC D OTHERDIA.02 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS__ <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEALS r TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED:,4-Yes 0 No (NOTE: MMI"MUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS. / �y�}� ! — <br /> 0 OTHER:_O <br /> OTHER APPROX.BORING DEPTH ----H- LTED TRAFFIC BOX or 0 STOVE PIPE <br /> n _ CONDUCTORS CASING PROPOSEf�j? <br /> 2 if YES,list specifications ere): <br /> 'COMMENTS: /"�'�''7 �'2 r h W�� i <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. <br /> Signed x <br /> u�c�� k Title/Company 4 � /61 <br /> Nr /7.C./ Date <br /> Print Name ��1 �uwc �7 C/ <br /> DEPARTMENT USE ONLY <br /> 9vJ0-C,6 <br /> SITE MAP IN UNIT IV FILE ADDRESS: "`�d � � <br /> WORK PLAN DATED: '.5O OGT 2000: L /siwvbIl J,pOd. <br /> Date Issued � ZOO / Area <br /> c <br /> Application Accepted By ate _ <br /> Grout Inspection By Date Final Inspection By <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 /> ZED 1 (003 /-/6-oi 00Z50(P <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit____Encroachment��oc� 9/27/00 <br /> :� copy <br />