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WELL r ZRMIT APPLICATION F{,. .id1 SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ORIGI <br /> NAL 304 E. Weber, Third Floor, Stockton, CA.,(209) 468-3449 95202 <br /> Ln �' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 2 2 2002 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i ade in ccmpliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Enlli=ctal3*Zlth C)Ildt9iSi41 <br /> FR�M�nT 5+. �M?,asseSsw�+��,��CE� <br /> WELL Location y I 0 C) 0,5 T FR e rn 0 n�' S} Cross Street O R O s+. City S To G K p y S 2) Parcel# <br /> PROPERTY Owner dRI /t G�ev+q� Address ylo o V=AST FRPw+Drrkity 3�sGK�LonZ,p `I�_Phcne# oal) y1 �bqs <br /> prrOr;jh'A503 <br /> FttojerG)D ST. AANLtIo 'f57gz <br /> C-57 Contractor 1r5 1- A Ahess SviFf_ CiCorOZip Lic# Sy �Phon l0 6 3� a <br /> b <br /> Consultant <br /> /Sub Contractor ,`.Ci.I— . Address 957 S Aw Rp AD City5%oc I ron Lic#�6n2z 7Phcnek2 0� y4 1/0o b <br /> GIS Coordinates:X ,Y ,Township Range Section ..0 <br /> d <br /> WORK TO BE PERFORMED: C7 <br /> DESTRUCTION(choose type below) <br /> JNEW WELL/BORING(CPT,GECPROBE.HYDROPUNCH,HAND-AUGER,OTHER') <br /> ` a OVER-BORE <br /> SOIL BORING# � <br /> 'WELL# NW-9 Q PRESSURE GROUT <br /> *Othera Grout Specifications: <br /> M -- <br /> COMENTS: ��� Ad�eno�..-� To W orlc Pr'oN Qq-rED / 7 Jul., Z o o / <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U,MONITORING R HOLLOW STEM DIA.OF BOREH _S <br /> CLE �____MULTIPLE CASINGS? Q YES frNO WELL CASING DlA: 2 <br /> xNfOvlE <br /> �EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL PVC O OTHER: <br /> []VAPOR p MUD ROTARY DEPTH OF GROUT SEAL )(rTREMIE TYPE TO BE USED: GAUGERS o HOSE <br /> Q AIR SPARGE 11PUSH POINT GROUT SEAL PUMPED: [I Yes DN,4o (NOTE: MAXIMUM FREE-FALL DEPTH 'AS 20" <br /> SOIL BORING ]]HAND AUGER GROUT SPECIFICATIONS: P-4 r T)A ND ck n�-fit- <br /> OTHER:_ ❑OTHER APPROX BORING DEPTH_ C? BOLTED TRAF=iC BOX or []STOVE P1FE <br /> CONDUCTOR CASING PROPOSED? /V o (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 /> 1 hereby certify that 1 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 Law/s.. / <br /> Signed x - Title/Company PR O QFC'i G Fo 0415% / A •6. r <br /> Print Name 1)Mo Tai J , V ti:P&+ Date L <br /> DEPARTMENT USE ONLY I �� <br /> SITE MAP IN UNIT IV FILE,ADD SS'' Z-11G <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDMONS: // <br /> ACCOUNTING ONLY: AID# L/W <br /> PE CODES FEE INFO AMOUNT REMITTED CHTCK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �c ` Y�`5 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permits Encroachment doc_ 9/27/00 <br />