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WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 �� <br /> (209) 468-3449 OFF 1qb'+ 111. <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 instttalI ll the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards r'Lan Joaq VeoTty Public Health Services,Environmental Health Division. <br /> Assessor's <br /> ELL Location Rri gPport Trails DeyelopCross Street Charter Waycity Stockton Zip 95206 Parcel# 163-0060-15 <br /> PROPERTYOwner San Joaquin Vally ASAddress 2333 San Ramon Va1W San Ramonzip 994490 hone#66- 0:4.467 <br /> WlbLA)FWA <br /> C-57 ContractorSTectrum F.xi 1 nrati9dtlress 2365 Dr CityStockton . 9520�ic#512268phone# 209-465-8712 <br /> Consultant/Sub Contractor Geomatrix Con. Address2444 Main St, #21�.ity Fresno Lic# Phone# 559-264-2535 <br /> GIS Coordinates:X 3]0 55.84' 1Y 1210 18,65' Township 1N Range 6E Section <br /> WORK TO BE PERFORMED: <br /> NEW 4ZEL /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') []DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> " HELL# TW—A, TW-11, TW—C, TW—D, [j PRESSURE GROUT <br /> 'Other: TW E, =_L Grout Specific ati s: <br /> COMMENTS: ��J(Q ,0 • <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ja MONITORING jd HOLLOW STEM DIA.OF BOREHOL��MULTIPLE CASINGS?[]YES IgNO WELL CASING DIA: 2" <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS Sch 40 PV(�YPE OF CASING: []STEEL PJPVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAN O — 11' bgREMIE TYPE TO BE USED: 1J AUGERS []HOSE <br /> []AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: 0 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 [I 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 /> hereby certify ttyt I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinal s, Rules an Regula 'o , d all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name (t 1440JV\ f- C?• �aUrtl^L'✓ Date Sa -7-3 —Cl <br /> CCD��EPARTMENT USE ONLY <br /> 64 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /oll al' .ol �MZAJS, �����'WORK PLAN DATED: L &a �T�� - OCA 140 D/ <br /> Application Accepted By Date Issued 7-i2 —O Area�Qo!_ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <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 /> Z9 o 1 ft <br /> M W S �" 03! oo71 7•s-o SR# Zoo 3 v /Ix_S9� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br />