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WELL PERMIT ,APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION PHS-EHD <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> n ,� (209) 468-3449 DEC 1 1 2002 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONWAT I-IEALI 1 <br /> .ppl , id'dis hereby made to San Joaquin County for a permit to constrict and/or Install the work described. This application iselwilh San <br /> oaquin County Development Title,Chapter 9-1115.3 and the Standards o(San Joaquin County.Public Health Services,Envlronm n edtlh ulv s, h. <br /> (� ` <br /> Assesso's h <br /> YELL Locatlon,�j. to-V S�'- _Cross Street Clly Zip�? -Parcel# V !/ <br /> 'ROPERTY Owne,. •(d i jl� -s � I� � 1 �O s-vr Iel DLA ratio d r _ t CQ <br /> v v t .1C YlU <br /> :-57 Contracto Address lD J L� m�.l�� City ZIp��Llc#1 QPhone# �C' - <br /> :onsultant/Sub Contractor dress �C(ly (0Llc# Phone# - <br /> :IS Coordinates:X Y Township Range Section <br /> VORK TO BE PERFORMED: <br /> I NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Z�!sESTRUC T iON(choose type below) <br /> p SOIL BORING# VER-BORE <br /> p WELL# U PRESSURE GROUT <br /> Other: Grout Specifications: <br /> ;OMMENTS: e-Q •(l 0At- e o0r) IL- 0. J <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES p NO WELL CASING DIA: <br /> I EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: [I STEEL [)PVC [I OTHER: <br /> I VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> I AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: []Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: U OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> county Or n s, Rules Regulations, and all applicable California State Laws. <br /> 31gned x n`-sem TIUe/Company - <br /> "dritName ` l ��'f� (''� �nV�,l l� -_ - Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ' f <br /> WORK PLAN DATED: �. 4 <br /> Application Accepted By '6 Date Issued / :Zl DZ _Area-­/4s'F <br /> Grout Inspection By IA&V MtAdf".94, -Datqifln 90 3 Final Inspection By_ ►0A4' Date 140-2,8b2 <br /> Destruction Inspection By Date - / 02 0 <br /> COMMENTS/CONDITIONS: -r y� <br /> ; ACCOUNTING ONLY: AID# I (� I 11 ' -0 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQU"$T 1 V <br /> ,3502. !10 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment dop �;,;;1 /�,�f, <br />