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WELL PERMIT APPLICATION FOM 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 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 /> JoaquinCu�even l ment Title,Chapter 9-111 .3 and the Standards % quip County Public Health Services,Environmental Health <br /> Division. <br /> Uri /� n /l-�L Zipf��-c&arcel# <br /> WE LL Loca wn d` p^/ !C Cross Streel /� i/� City S�/ <br /> PROPERTY OwnernLL G` �,-.���L A//d��dress,- TYZ lkcl /' City Cc //d�ip Phone(CS3�S <br /> C-57 ConlractorA c�J AddressYDS' at�7� City �v.7 Zipyrq(�4ic#�mo Phone�f <br /> �� E�OrC'/ Address o'� c- `�Y/'7City. _Phwe# yam'-/J7) <br /> Consultant/Sub Contractor IL c <br /> GIS Coordinates:X <br /> y.,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> XNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> ;-R ()1 BORING � � �� OVER-BORE <br /> []WELL# � PRESSURE GROUT <br /> *Other: <br /> Grout Specifications �4'-c-0-1 <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �-_`rONITORING 0 E <br /> HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES kNO WELL CASING DIA: /L/ <br /> KNESS /tib TYPE OF CASING: _STEEL _PVC _OTHER: <br /> EXTRACTION _AIR HAMMER/DRIVEN CASING THIC <br /> _ TREMIE TYPE TO BE USED: _AUGERS 'HOSE <br /> VAPOR _MUD ROTARY DEPTH OF GROUT SEA <br /> _AIR SPARGE PUSH POINT GROUT SEAL PUMPED: [)Yes 14-,No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> _SOIL BORING _HAND AUGER GROUT SPECIFICATIONS: e -Q W <br /> _ <br /> OTHER:_G OTHER APPROX.BORING DEPTH ��,2 ' 0 BOLTED TRAFFIC BOX or _STOVE PIPE <br /> / <br /> CONDUCTOR CASING PRO P SEDT /v if YES,list specifications here): <br /> •COMMENTS:.ga �`)r� �`�n � � O / <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 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 al &r�ifoia �ws•��/f <br /> Signed x Title/Company 'k <br /> ('2 <br /> Print NamDate <br /> es DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: � [ / � <br /> IM <br /> Application Accepted By �� _Date Issued 1/3� Q Area <br /> Grout Inspection By <br /> Date Final Inspection By K � Date <br /> Destruction Inspection y Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1990/ q00 A"ii3yl (,b 413/Dx sg# M.2$1333 <br /> C-57_ WC=WAIVER_ C-57 Letter at Authorization to sign permit_Encroachment doc_. 9/27/00 <br /> i <br />