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WELL I- .-rRMIT APPLICATION FOR`, SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 3 S�_ <br /> Id Pi; 304,F­ Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNOA— E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Aoplication 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 /> Yuaquin County Derveloypm�ent Title.Chapter 9.11�15y.3 and the Standards of San/Joaquin County P Health Services,Environment Asscssofsl Health Division. <br /> �'�. df q0 i{/,t /NCa:tA JL•. Cross Street �!/S7 City op(/! Zip• Parceltt <br /> WELL Locationyr�1 y� !�j �G ..-tet <br /> I�` .1175! r .7C . City Zip �f_Phonerr <br /> PROPERTY Owner_ M� Address <br /> / (' e At'nst,� Address1�poo Tf,.�a�cd�Ic�City�.}�, zipc�g3;�Lic>+�a¢fLPhone>r =, ? �'3 j <br /> C-57 Contractor Ct�/ t r <br /> Consultant/Sub Contractor/' Re-,—L'll.a��j}j�,����� gg pp GAddressS3m L�at(rrtt��Cibta3�t�s°3�LicY,��a'f ZPhonert � <br /> GIS Coordinates:X____ <br /> Y ,Township Rang¢_ section <br /> V10 K TO BE PERFORMED: F 0 DESTRUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROSE,HYOROPUNCH,HAND-AUG-IR,OTHER') 0 OVER-BORE <br /> 0 SOIL 0 0 R I N G k E �..�_�-- 0 PRESSURE GROUT <br /> 0 WELL kGrout Spoei111 b� <br /> fications:�.<:.cr -e�t5 �-11A� tae.oe�...!ttre.c��¢v��.•��WAtfw4> <br /> 'Other: <br /> COMMENTS F,((ti r1. k0 5 Ft tt nbc �t(fi- WAtt2 tn171twt bio va Jtl�r+s :0.11owe ltol� tt "^v tv.Z <br /> tO S'JQ-ft•L�INy ('tMAN.^•� byr•r ii'W lit."/t NLe��CEn!} <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS *l O Sv FAQ+ <br /> C)MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> v <br /> 0 EXTRACTION 0 AIR HAhlititERlDRIvEN CASINGTHICKNESS -. TYPE OF CASING: 0 STEEL D PVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIG TYPE TO BE USED: []AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT 5PECIFICATIONS:__: IBOLTED TRAFFIC BOX or 0 STOVE PIP <br /> 0 <br /> OTHER;__...-—O OTHER_ _— APPROX.BORING DEPTH D <br /> CONDUCTOR CASING PROPOSED? (ir YES,list specirc-ations 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 /> I hereby certify that I have prepared this applic ion and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rul s and Reg lations, d all applicable C lifornia State Laws. <br /> r <br /> Title/Comp Y�_.. -•• <br /> Signed x _. <br /> Print Naina,• DEPS M ONLY <br /> SITE MAP IN UNIT IV LE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Area_,r,__ .— <br /> Applicatrort Accepted By ,_ - Dale <br /> Final Inspection By <br /> Grout Inspection By -- <br /> Date _ -- <br /> Ueswction Insuectlon By Date <br /> COMMENTS/CONDITIONS: _. <br /> ACCOUNTING ONLY: AIDK <br /> DATE PERMR 7 SERVICE REQUEST# INVOICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK p RECD BY <br /> _ 9/Z7/00 <br /> C.57— WC -WAIVER— C-57 Letter of Authorization to sign permit_Eneroochment doc_ <br />