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c l WELL eERMIT �`+►I�P',�.I�ATI®N FAM _SITE <br /> MITIGATION <br /> REC , `� �u L� HEALTH UNIT IV <br /> SAN JOAQUIN COUNTY EA'�THLniVIS ON (PHS EHD)SERVICES <br /> JAN 2 1 2004 ENVIRONMENTAL 86202 <br /> 304 E. Weber, Third Floor, Stockton, Ca, <br /> ENVIRONMENT HEALTH (209) 468-34.49 <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERri, MIT EXPIRES 1 YEAR FROM DATE ISSUEDIs made In <br /> Application is hereby made to the work described, This applicallon <br /> San Joaquin County foraa perm <br /> It <br /> S�ndards of Sanct /Joaquin County Pub Health Services EnvironmenlaI HAsseealth IDivis nth San <br /> Joaquin County Development Title,Chapter 9-1115 3 So zip 9520 Parcel# <br /> 3? Svu Cross Street—&4-L—City <br /> WELL Location " 9S2G�Phone#ZO°i�3�9 <br /> / b+1E'3^ -r' ��-CG+�rlSfn ZJp <br /> PROPERTYOwner Aeh�c K �`�n 9510 Si226 hon0# '�s'o-71Z <br /> �wh Address Z3G f��sG Ci`y [f' (�r�Li��c# <br /> C-57 ContracDorS�r�� "n�°f'L (J .Ci cTi` uit# NA. Phone#17-5 4I-370D <br /> Consult tlSubContractor pG165 — -- I � C �-- ty--' <br /> S�� / Section <br /> GIS Coordinates'-X •Y <br /> Township I f Range <br /> DESTRUCTION(choose type below) <br /> WORK TO BEPERFORMEM. <br /> HyDROPUNCH,HAND-AUGER,OTHER ) 0 OVER-BORE <br /> 0 NEW WELL 1 BORING(CPT,GEOPROBE, )KpRESSURE GROUT <br /> 0 SOIL BORING# <br /> 0 <br /> WELL# Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICI?IONS S IXNO WELL CASING DIA:_ZL <br /> TYPE OF WELL ,MULTIPLE CASINGS. it <br /> (v10NITORING Q <br /> HOLLOW STEM OIIL OF BOREHOLE PVC ❑OTHER: <br /> 0 EXTRACTION []AIR HAMMER/DRIVEN CASING THICfCNESS SC44-40 ��M EN�pTo7BE USED: Q AUGERS 0 HOSE <br /> 0 VAPOR 0 NtuD ROTARY DEPTH OF GROUT SF1aL <br /> 0 AIR SPARGE Q PUSH POINT <br /> GROUT SEAL PUMPED: ` Yes Q No (NOTE: MAXIMUM FREE-FALL DEP <br /> IS 30') <br /> RING UGER GROUT SPECIFICATIONS: <br /> APPROX_BORING DEPTH 6G Er Q BOLTED TRAFFIC BOX or <br /> 0 SOIL BOQ HAND A �STOVc PIPE <br /> 1]OTHER if YES,list specifications here)= <br /> 0 OTHER: <br /> CONDUCTOR CAST G PROPOSED. _(if S g <br /> r, o <br /> ,COMMENTS: w (i . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT <br /> NoR CR (lUIRED NSPECTSIONs. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVAN <br /> b certify that I have prepared this application and that the work <br /> Porn Gill be done in tate Laws. accordance with San Joaquin <br /> I here y ty Regulations,and all applicable <br /> countyordin�flces, Ie a dReg <br /> TitielCOmpany <br /> Signed x ( Date I 9 4- <br /> C. k:�t�e6', <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: � v Area— <br /> Date <br /> — <br /> Date Issued '' �i <br /> Application Accepted Byion By Date <br /> mal Inspect <br /> Grout Inspection BY y Dat Z Z <br /> Destruction Inspection r <br /> COMMENTS!CONDITIONS: cCPp <br /> ACCOUNTING ONLY: PERMITISERVICE REQUEST# INVOICE <br /> Y <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK RECD �{DATE <br /> O� , X 9/27/00 <br /> 1-1 -57 Letter of Author ratio t sign permit Encroachment doc <br /> C_57 Vy/C -WAIVER C <br />