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WELL PERMIT APPLic4f- lc '� SATE <br /> 04 .,.`MITIGATION' <br /> I. SAN JOAQUIN COUNTY PUBLIC HEALTH�1�18A UNIT'IV <br /> ENVIRONMENTAL HEALTH DIV1S10I`t fflK§MR)-HEALTH <br /> 304 E. Weber, Third Floor, Stockton, IRA�PVICES• � <br /> (209) 468-3449 <br /> NON-REFI3NDABLE PERMIT EKPIRES 1 YI:.AR FROM DATE ISSUED <br /> 4ppllcatian is hereby made to San Joaquin County far a permit to construct and/or install th,e work described. This application is made in compliance with San <br /> Joaquin County Deveianrnent'Titie-Chanter 0-11-1r,.3 and the Standards of San Joaquin County Public Health Services,Environme Cl SeHealth Divi 403 <br /> ---�a l_� o - +-. Ta Parcel# iJ <br /> NELL Location Y 1. rY _. Cross Street Cityy1� ( P <br /> _ _._t r _� r ;tv-'� 0(, 4�Zip Phona# <br /> °R©PERTY Owns,[r S 0 Address J _ W ' G !+_ p r -- <br /> V yet Address- - CitYJ Z'F W`I `f�ic# - <br /> C-57 COntr3CtG 4 + �r Ktik'Y <br /> IlZo SZ'�y <br /> Cay nsutJta t t sub Contractor s ft�'r C� S!_���'^�ddress: O �'� S Cjty�1 Lic# Phare# "f -_ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFOR ED: DESTRUCTION(choose type below) <br /> ANEW WELL I BORING(CPT,GEOPROBE,HYDFiOPUNCH,HAND-AUGER.OTHER-) fl 0 OVER-BORE <br /> SOIL BORING# a PRESSURE GROUT <br /> DWELL# - <br /> *Other. Grout Specifications, <br /> I CL)MMENTS: <br /> TYPE OF 1ryELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING p HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES ONO W ELL CASING DIA: <br /> EXTRACTION []AIR HAMMEWDRIVEN CASINGTHICKNESS TYPE OF CASING:. ]]STEEL []PVC. []OTHER: <br /> 0 VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:, II AUGERS 0 HOSE . <br /> U AIR SPARGE0 PU81i POINT GROUT SEAL PUMPED'. 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> t g SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> p-fHEg; a OTHER APPROX-BORING DEPTH . 0 BOLTED TRAFFIC BOX or CI STOVE PIPE <br /> I CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 1 "COMMENTS. ,. �2� O V�)�t �Zr crr•: - - <br /> - z, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS-OR-ENCROACHMENT PERMITS. i <br /> CALL,THE UNIT IV INSPECTOR 48 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 Or nee s an gulations,and all applicable California State Laws. <br /> r <br /> Title company �/�.®!/� /r• //!r <br /> Signed x /eG CT <br /> f Print Name Date — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> ' WORK PLAN DATED: <br /> Application Accepted By Date Issued, � �`�� Area <br /> Grout inspection By Date Final Inspection By Date. <br /> Destruction Inspection By Date <br /> COMIKENTS I CONDITIONS: C <br /> ACCOUNTING ONLY: A S ( r au <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DA PERMIT I SERVICE REQUEs-r# INVOICE <br /> f C-57— WCC WAIVE{t— C-57 Letter of Authorji -i" �. gn rmit_Er <br /> icroacFtment hoc 9/27/40 <br /> E@ ridd 8007A HIJIA EEt;E89b69Z 99:Et t09Z/13Z1Z0 <br />