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6 <br /> nn WELL PERMIT APPLICATION FO SITE <br /> W ECE] V E� MITIGATIONS <br /> SAN JOAQUIN'COU.NTY PUBLIC HEALTH SERVICES_ .UNIT IV <br /> APR 1 3 2001 Y ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA.; 95202 C��.��Co.S <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES <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 Public <br /> Health Services,Environmer�$eeall SDivision. <br /> WELL Location - Cross Street 7r1+city�� 7iP �� Parcel#F <br /> w <br /> ' � r rr Zip - hone# 9� <br /> PROPERTY Owne Addess4 ;n ?I- <br /> f�/0 <br /> U� <br /> C-57 Contractor Address AP City. Z5WLL1c#S1IhOne#_ 7 <br /> one i�c# Ph <br /> Consutant/Sub Contractor Address <br /> 7� <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WQW TO BE PERFORMED: <br /> EW ]DESTRUCTION(choose type below) <br /> WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER <br /> �OVER-BORE <br /> []SOIL BORING# [l PRESSURE GROUT <br /> pWELL# <br /> *Other: Grcut Spedfi tins: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS x a 12%c_ <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE "' LTIPLE CASINGS?d YES�O WELL CASING DIA: <br /> EXTRACTION 0 AIR I tAMMERlDRIVEN CASING THICKNESS M A- TYPE OF CASING: [I STEEL.A 0 OTHER: <br /> �VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL? � TREMIE TYPE 70 BE USED:�IGERS []HOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: �es p No (NOTE: MAXIMUM FREE-FALL DEPTH 15 30') <br /> a SOIL BORING HAND AUGER GROUT SPECIFICATIONS ���p _� LIED TRAFFIC BOX or [I STOVE PIPE <br /> 11 OTHER: [l OTHER APPROX.BORING DEP'T�� r� <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: 1 r A <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. / <br /> Title/Company e� ' <br /> Signed x <br /> Date 13 <br /> Print Name DEPARTMENT USE ONLY <br /> 7 )i <br /> SITE MAP IN UNIT IV FILE,ADDRESS' <br /> WORK PLAN DATED' <br /> Date Issued ea :� <br /> Application Accepted By Date o <br /> Grout inspection By Date Final Inspection By <br /> Destruction Inspection Byy Date <br /> COMMENTS/CONDITIONS: <br /> FCCOUITING ONLY: AID# <br /> ES FEE INFO AMOUNT REMITTED CHECK# REC•D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> tl aTAvW5 /3�a • <br /> C-57 W( -WAIVER2 C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />