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MD WELL PERMIT APPLICATION FbW SITE <br /> t� MITIGATION <br /> OCT U 2 299A SAN JOAQUIN COUNTY <br /> PUBLIC <br /> DIVIS ON (PHSSERVICES <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH Ep•�1►1' .C''vti�jL'a� ATTR 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> pERMiTiSER;;CES - (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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmentalalth Division. <br /> AsseWELL Location ad d Cross Street il�( I/ City LIK7-OAf Zip��Parcel# <br /> PROPERTY Owner-WMAJ S 5WA0ftjfCr Address WL) to Vt' GH! A&92 City S7d-7Af �p 9 a7 Phon <br /> C-57contrar�orFi�ritLb�I ��.1(l�.i(,rAddress 536 S. i�i�'T7` AL�bE.City:�,g .r�7jp9SLZ UUc#67 k Phone# gt4)631�3S7.3 <br /> rllrl/A��t�i�(/�t71L�i08t/MB+�fA�lddresS�W.�lf Clty; rjra- Uc# Phon 4� <br /> Consultant/Sub Contrado e,�„_ <br /> GLS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(C ��BORINGpROPUNCH,HAND-AUGER,OTHER-) <br /> /PERFORMED: )( ADESTRUCTION <br /> 0 WELL PRESSURE GROUT <br /> Grout Specifications: IOQTLAsIn 'rel I <br /> COMMENTS: Oti!ilbet CCS ' b*t T - FILL- W1647 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: .0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,Hsi 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 i have prepared this application and that the work will be done in accordance with San Joaquin <br /> Countya ill s and Regulations,and all applicable California State Laws. <br /> Titie/Company ST <br /> aV R <br /> Signed x <br /> Date <br /> Print Name I AU L �T SD"� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �l <br /> Application�pl�By WAKate <br /> Date Issued <br /> v Area <br /> Grout Inspection By nal InspectionyDeshudiort fnspedion ey <br /> COMMENTS/CONDITIONS• <br /> ACCOUNTING ONLY: AID# <br /> pE CODES I FEE W FO AMOUNT REMITTED CHECLA <br /> EC'D Y DAT PERMIT/SERVICE REQUEST# INVOICE <br /> 0.00 o a <br /> C-57 WC -WAIVER C-57 Letter Iz io to s n permit Encroachment doc 9/27/00 <br />