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FOw <br /> IV <br /> WELLERMIT APPLICATION FM,11 SITE' 4 <br /> IMIT GATION <br /> N �.,C <br /> SAN JOAQUIN COUNTY:PUBLIC HEALTH SERVICES, UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EI- D)JIRONlviEnlTAi wA1 H <br /> 304 E. Weber, Third Floor, Stockton, CA., 95201 RE MITI SERVICES �i <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environme Asses Health Division- <br /> WELL Location 1 Cr ss Street City Zi r Parcel# <br /> QJ' City.S zip 2�9Phone# �7�5��� <br /> PROPERTY Owner`P _ ddress / <br /> VU�S �ddress ` C City Zi�Lic;��Phonef9A k u"-A-7p <br /> C-57 Contractor �+ <br /> Consultant!Sub Contractor/h+-7 ^1��� AddresskD <br /> City Lic# 'hone# `Y�7� }0 <br /> GIS Coordinates:X <br /> Y Township *� Range Section <br /> RELW <br /> TO BE PERFORMED: !� DESTRUCTION(choose type below) <br /> WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER'} Il OVER-BORE <br /> SOIL BORING# <br /> LL# p PRESSURE GROUT'. <br /> �tlVE / <br /> `Other: �\ Grout SpeciScations: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT! NS <br /> W TEM <br /> DIA.OF BOREHOLE 'r' I TiPLE CASINGS?©YES �VO WELL CASING DIA: <br /> MONITORING LLO STEM <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ��l TYPE OF CASING: []STEEL PVC (]OTfIER. <br /> VAPOR [ MUD ROTARY DEPTH OF GROUT SEAL -�'�� TREMIE TYPE TO BE USED: A UGERS. -_[]HOSE <br /> a AIR SPARGE p PUSH POINT .--GROUT SEAL PUMPED:.[Yes)kNo,(NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br /> k U SOIL BORINGS [l HAND AUGER GROUT SPECIFICATIONS: LTED TRAFFIC BOX or Q STOVE PIPE it <br /> (}OTHER: O OTHER APPROX.BORING DEPTH LOQ <br /> CONDUCTOR CASING PROPOSED? A� (if YES,list specifications 04") here): <br /> u�et!C T <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 /> hereby certify that 1 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 /> f <br /> Signed x Titie/Company <br /> Date <br /> Print Name <br /> DEPARTMENT USE ONLY . h I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date <br /> Issued <br /> Area �- <br /> h Grout Inspection 8y Date Final Inspection By ' Date <br /> I Destruction Inspection By Date s 'I <br /> E <br /> COMMENTS I CONDITIONS: <br /> k ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> S bt -73 <br /> S �� 2 L,► - 6�� of bD2�� <br /> i C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> I <br />