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WELAERMIT APPLICATION ARM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />ORIGINAL 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 />�/ tI ``11 ` - I l Assessor's <br />WELL Location M7 N W£Sl �- (1• Cross Street Cl C� �eS S�. City Zip �ZD Parcel# 104 <br />PROPERTY <br />—10 <br />(1 - <br />PROPERTY Owner_`lo � Coc�.tv.v> Address (o�\ �yICQn L4m, CitySa.-\ �pero.� —Zip 19S-81. Phone# 9ZS-S TL—� LSS" <br />C-57 Contractor Q&-'tLi,�2'Q ,A , t Address N -S -L dm2L- Cict���v City 2A h Zip �2 Lic#T-jS]D Phone# <br />Consultant/Sub Contractor 1�1-IECCA& AddressSU-1,0City co(zco., Lic# Phone# No-&I'07uV <br />GIS Coordinates: X , Y , Township Range <br />Section <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [] DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE --1 <br />;HWELL # [] PRESSURE GROUT <br />*Other: Grout Specifications: S <br />COMMENTS: <br />TYPE OF WELL <br />16}�(IONITORING <br />EXTRACTION <br />[]VAPOR <br />[] AIR SPARGE <br />[] SOIL BORING <br />INSTALLATION TYPE <br />P4zt�LLOW STEM <br />[] AIR HAMMER/DRIVEN <br />[] MUD ROTARY <br />[] PUSH POINT <br />[] HAND AUGER <br />[] OTHER: [] OTHER <br />*COM <br />CONSTRUCTION SPECIFICATIONS c— <br />DIA. OF BOREHOLE '6"' MULTIPLE CASINGS? (] YES 0 WELL CASING DIA: Z <br />CASING THICKNESS 5�� V TYPE OF CASING: [] STEEL PVC [] OTHER: IN <br />DEPTH OF GROUT SEAL �U t� TREMIE TYPE TO BE USED. �UGERS [] HOSE <br />GROUT SEAL PUMPED: /Yes [] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: tAcfxy Cea-- eN\y <br />APPROX. BORING DEPTH (nO /�OLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED?_if YES, list specifications here): <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 Ord4 anee a__nd Regulations, and all applicable California State Laws. \ �— <br />Signed x ^i Title/Company <br />Print Name �� Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />DEPARTMENT USE ONLY <br />©/ <br />Application Accepted By I Date Issued �?? / Area <br />Grout Inspection By /v Date i Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />C Artt <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE <br />C-57_ WC= WAIVER C-57 Letter of Authorization to sign permit <br />MIT / SERVICE REQU_M <br />:ncroachment doc <br />INVOICE <br />9/27/00 <br />