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WEIL PERMIT APPLICATIOI�ORM M <br /> MITIGATION <br /> TGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> DEC 2 0 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (208) 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 deswoed. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter&1115.3 and the Standards of San Joaquin County Public Health Services,Ewironmental Health Division. <br /> WELL Location /5''/3 S pC16#T-MIDI./E�k D c vss St eet 6g8LA n�9kjty ,S7dLKro� zip 9�/�9 Parcel# dr�0'� <br /> PROPERTY Owner 4OM!WX'/(>L1/G''�S / 'N/`p��'�A'dgdress/S-1'',��71*H-TMjLh �/�CIry STiC�q,-',rZIp a1 Phane#Uj gSl 4G3y <br /> C-57 Contractor Q/Urr,M.Y e�n/lJ�f.DCJuUI/L /Address B 7 fhlAw� A !C-i1 7 L Zp�uo# Phare#�� �G 7'/006 . <br /> Consultant]Sub Contractor /y' //At/(,E7� /Yk��/ / ,Address Y�7,2,WW&2 Cary SQA' uc#GSQ2i�Phone# 1.OS l/G7"l�6 <br /> GIS Coordinates:X <br /> Y ,Township Range Section <br /> WORK TO BE PERFORMED- [I (choose type below) <br /> U NEW WELL/BORING(CPT.GEOPROBE,HYDRCPUNCH,HAND-AUGER,OTHER') OVER-BORE <br /> SOIL BORING# 76�D TJ14��P�Nt/SINt!7� �N dd*(5 Sr mr- I]PRESSURE GROUT <br /> WELL# <br /> - Grout Specifications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE Z rrrr <br /> MULTIPLE CASINGS?Q YES VNO WELL CASING DIA:N<L <br /> 11 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS__jv,4- TYPE OF CASING: U STEEL ❑PVC 0 OTHER: <br /> o VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 50 r TREMIE TYPE TO BE USED: WAUGERS 11 HOSE <br /> PUSH POINT GROUT SEAL PUMPED: 13 Yes Q No (NOT1C�ISM FREE-FALL DEPTH IS 301 <br /> Q AIR SPARGE <br /> HAND AUGER GROUTSPECIF(CATIONS: P <br /> '.SOIL BORING U 0 r BOLTED TRAFFIC BOX or E STOVE FIFE <br /> a OTHER: f1 OTHER APPROX.BORING DEPTH 5 D <br /> pp CONDUCTOR CASING PROPOSED?_ ./A (if YES,list specifications here): <br /> 'COMMENTS- f�GRIAI(e S O/ 4- <br /> G �LlJ`S/P7H/�CL�' r�G �Cli1/ <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 /> County Or noes a Regula, and all applicable California State Laws. �� /I <br /> Signed x <br /> � Title(Company <br /> �n ��7 Date--Zi O/ <br /> Print Name DEPARTMENT USE OONLY <br /> SITE MAP IN UNIT N FILE,ADDRES : I S 1I�— <br /> WORK PLAN DATED: 5I __7 16 1 q <br /> Date Issued I Area l Y 1 <br /> Application Accepted By <br /> Grout Inspection By - Date e S Final Inspection BY <br /> Destruction Inspection By Date <br /> COMMENTS/CONOTnONS: Y n Sr G 0 ��' 01 .Z co fd c Or Sr z 10 l$ 6Y <br /> Opt <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REWD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to Sign pumit_Encroachment clot_ 9/27/00 <br />