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WELLARMIT APPLICATION FbiRM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to oonstruct and/or Install the work described. This application is made in compliance with San <br /> Joaquin County Development JTiitle, <br /> • �' �l Chapter�9-11 5�.3P d the S`aI`nn�dTMa"rd,G�t�3i o"�°'S`,^a,Innja"q�oCunit[y�CPublic Health Services, <br /> Environmental Health Division. <br /> eZiftelc Parcel# <br /> WELL Locations tyy6 Phonee <br /> C- dyes <br /> PROPERTY owner <br /> / f / <br /> ` C-GCr3 �- ddress t0 1�e�t.� ' c�honetl ��0�1GF7 ' <br /> C-57 Contractl J <br /> V �� <br /> Consultant!Sub Contract ddres <br /> Range Section <br /> GIS Coordinates:X .y_,.Township <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> Q NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') Q OVER-BORE <br /> Q SOIL BORItl # Q PRESSURE GROUT <br /> WELL# I Grout Specifications: <br /> •Other- <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP CIFICATIONS <br /> ,MONITORING HOLLOW STEM DIA.OF BOREHOLE 't 1 MULTIPLE CASINGS?Q YES [)NO WELL CASING OIA: <br /> (I EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNES iA TYPE OF CASING: Q STEEL INPVC Q OTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL t TREMIE TYPE TO BE USED: AUGERS I7 HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: 11 Y s o {NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS: OLTED TRAFFIC BOX or STOVE PIPE <br /> Q OTHER: []OTHER APPROX.BORING DEPTH <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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance With San Joaquin <br /> County Or ances, Rule Regulations,and all applicable California State Laws. <br /> ia <br /> Signed x Title/Company ___T1 acl ` ,C�j�t, <br /> Date - <br /> Print Name <br /> -DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: I <br /> Application Accepted By <br /> Date Issued Area ,Y <br /> Grout Inspection By <br /> Date bL Final Inspection By �.` Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDr IONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK B RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc 9/27/00 <br /> E0 39Vd 210013 H13I3 CEPEO906OZ IE:EZ 0002/V0/ZZ <br />