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ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 4'"'"'� * "' (209) 468-3449 OFF �Ro4 W. <br /> rZu.D�i � �� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v <br /> Clication 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 /> quin County Development Title,Chapter 9-1115.3 and the Standards San Joaq m Co ty Public Health Services,Environmental Health Division. <br /> resno `�1ve ' Assessor's <br /> LL Location Rri dgeport Trai 1 s DevelopCross Street Charter Way ity Stockton Zip 95206 Parcel# 163-0060-115 <br /> PROPERTY Owner San Joaquin Vally As Address 2333 San Ramon Vary San RamonZip 949 41hone ' ho-AR <br /> W 16.U)AfA <br /> C-57 ContractorSTectrum Ex=l ornti ress 2365 Dr City StocktorEip 9520lic#512268Phone# 209-465-8712 <br /> Consultant/Sub Contractor Geomatrix Con. Address2444 Main St, #21Ftity Fresno Lic# Phone# 559-264-2535 <br /> GIS Coordinates:X 870 55.84' Y 1210 18.65' Township 1N Range 6E Section <br /> WORK TO E PERFORMED: <br /> NEW 4FfL /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) []DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> 1NELL# TW—A, TW—R, TW—C, TW—D, PRESSURE GROUT <br /> *Other: mr,_E,� F r ,��Grout Specific t* s: O <br /> COMMENTS: ,p � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> :R MONITORING jj HOLLOW STEM DIA.OF BOREHOLE''8" MULTIPLE CASINGS?[]YES 1g NO WELL CASING DIA: 2" �. <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESSSch 40 PV0YPE OF CASING: []STEEL If PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAN 0 — 111 bgREMIE TYPE TO BE USED: fjAUGERS []HOSE <br /> []AIR SPARGE [J PUSH POINT GROUT SEAL PUMPED: []Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: Cement/Bentonite Mix (< 5% Bentonite) <br /> []OTHER: []OTHER APPROX.BORING DEPTH 30' bgs []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (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 tlyt I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina s, Rules an Regula 'o s,9Ad all applicable California State Laws. / <br /> Signed x Title/Company t�/c 4lG�P_Gt�t/. 7 c_ ef, 5 l p <br /> Print Name 5 M0 JV ��(J�1��°✓ Date -7-3—6i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: / 4/' 57ZN, C✓4a&Ca <br /> WORK PLAN DATED: G W ASSAw7f - T O,C,e 41 <br /> Application Accepted By Date Issued 7-/ _.01 WW W <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date 010 41 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> L90 MW 8 03! 75.01 SR# 2� 30 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />