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0 0 <br /> f^t�%,IIt �IggE��tA,. HEAI TH WELL PERMIT APPLICATION FORM SITE <br /> CrRVICT SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> UNIT IV <br /> 03 OCT I I p!1 il' Q4 304 E. Weber, Thi(209) 468 3449 ton, CA., 95202 <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 Environmental Health D p irtmepl. <br /> ssors <br /> WELL Location aooN ,6eeeM4v Cross Street V1CT0r City-Loo, 5Zc6'Paseel# <br /> Zip Parcel# <br /> PROPER <br /> owner S C Address �7.r�-9S4 <br /> /9/i,/,, /�1 /city 'ta'c�{�yj�V/�Zb Y�-V Phone# <br /> C-57 Contractor S z Address-1'367 �f�N As A/.�� City o46ki '# ip IrA" Lic#���✓B Phone# 4t s-$-71a <br /> Consultant/Sub Cntr Kk l� L ld�l Address 0911 & City Lic# Phone# :209 4'/16 /3ys <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDRQPUNCH.,HAN/AUGER,OTHER*) O DESTRUCTION (choose type below) <br /> SOIL BORING#_ Q 3 ( 3ar 3` So OVER-BORE. DIAMETER <br /> XWELL# MW,' I1y Q '�(0' ) a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: ar/ <br /> pEXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS SCk 110 TYPE OF CASING: a STEEL XPVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED: $AUGERS p HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `XSOIL BORING (3) a HAND AUGER GROUT SPECIFICATIONS I <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH �0 ABOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A10 (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinanc ,, �Rules <br /> �and 'R/Aeyp/ulatio , and all applicable California State Laws. /- r <br /> Signed x a/wy��-L,4y� /v /'1 Title/Company 54a,4+ biV <br /> Print Name 1 ?1?011� Date / () <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �,a� <br /> Application Accepted 8y Dale Issued l l�.l �✓ , � f Area <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: O' I 770 <br /> ACCOUNTING ONLY: AID# C A✓>t 0. er 2p2 0' <br /> FAC# nj .Vil <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D{BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O ( C7 � l0 ZD Q3 SR# G, �Z <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth izati t sign permit_ Encroachment doc_ 9/30/02 <br /> a6 MM SV-, D <br />