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vk =,a j IL ► <br /> k <br /> WELLERMIT APPL'KATION FM <br /> SITE <br /> - SAN JOAQUIN COUNTY PUBLIC HEALTH 5ERVICE5 MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stocktor>I i,�CA.,�,95202 L <br /> (209) 468-3449 <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 describes. 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 /> 4 ,� Assessor's <br /> kWELL Location LV '�IeI' A ��' <br /> F Cross Street jVJ$ City Zip 9s40�an el# <br /> PROPERTY Owner 1f Address Zt+ ' Ci z7 Z <br /> PR - ty Zip Phone#� <br /> C-57 Contractor !/jW P/t Ue 4A Address cityZip Lic#�� <br /> 7 <br /> '�i !i <br /> Lic# Phone# <br /> }-1 �7 <br /> onsultantlSub Contractor�/1G�If�[ L���._ Address�.fJ� ��'c..�` ��/C�7 .ty� Teta <br /> k <br /> GIS Coordinates:X 'y Township i Range Section <br /> WORK TO BE PERFORMED: !A <br /> 1�{VEW WELL!BORING(CPT,GEOPROBE,HYDROPU CH,HAND-AUGER,OTHER") []DESTRUCTION(choose type below) <br /> ! SOIL BORING# i "� 0 OVER-BORE <br /> t. [j WELL# f []PRESSURE GROUT <br /> -Other: Grout Specifications, <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORINGHOLLOW STEM DIA.OF BOREHOLEW MULTIPLE CASINGS?©YES�t� WELL CASING DIA: <br /> n EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYP}E OF CASING:O STEEL I1 PVC ©OTHER: <br /> a VAPOR (]MUD ROTARY DEPTH OF GROUT SEAL`TREMIE TYPE TO 13E USED: o AUGERS ©HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED:111-yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 4� M <br /> � � <br /> — <br /> U OTHER: [I OTHER APPROX.BORING DEPTH � I �BOLTED TRAFFIC BOX or a <br /> STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?—:[ 0if YES,list specifications here): <br /> k 'COMMENTS: Sj <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE , <br /> FOR ALL REQUIRED INSPECTIONS. <br /> ai <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' ces, lealRegulati s, and all applicable California State Laws. <br /> Signed x Title/Company W i <br /> Print Name Date P et <br /> I4 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J.w $14 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By <br /> Date i kll! <br /> COMMENTS!CONDr IONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE !'PERMIT l SERVICE REQUEST# INVOICE <br /> 9,17 — 14� bg !z-1-pct ii �U <br /> C-57WC -WAIVER C-57 Letter of Authorization to sign permit jl Encroachment dock 9/27/00 <br />