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:' WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN J©A4UIN COUNTY PUBLIC HEALTH H EH13 SERVICF-S <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (P ) <br /> 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> " (209) 468-3449 <br /> NDN-REFUNDABLE PIrRMrr EXPIRES 1 Y1=AR FROM DATE.ISSUED <br /> application is hereby made to San Joaquin County for a permit to con rt and/or install the work described. This appl=tion is made in compliance with San <br /> th <br /> Joaquin County Development Title,Chapter 9-1115.9 and the Standards of Sari Joaquin County Public Health Services,Environme AsSeH sor's Division.'.. <br /> rass Street ''Zip Parcel# <br /> �' Clly <br /> NEELL Location,_, <br /> PROPERTY Own�er G-` � \�• AddrOess tcWC'it�y'Sr.kkJ <br /> UZp Ph <br /> one# <br /> pSbAI 4,APhonew <br /> !s �4 I <br /> dressCity <br /> C-57 Contractor <br /> ------ <br /> w�T, Phone# <br /> Z UA <br /> Consultant 1 Sub Contractor �o S� Clty�� `�S -L.Lk <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFOR ED �DESTRUCTION-(choose type below) <br /> U NEW WELL f BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTKER') OVER-BORE <br /> G SOIL BORING# []PRESSURE GROUT <br /> %WELL# <br /> *Other. Grout Speclficatlons: <br /> i, <br /> COMMENTS: <br /> r <br /> TYPE OF V�fELL INSTALLATIONTYPE GO TRUCTION SPECIFICATIONS <br /> �I+AONITORING [}HOLLOW STEM DEA.OF BOREHOLE MULTIPLE CASINGS?1]YES p NO WELL CASING D]A"� <br /> Q EXTRACTION ll AIR HAMMER/DRIVEN CASING THICKNESS TYPE=OF GASlNG: �]STEEL PVC. OTEiER: " <br /> [i VAPOR p MUD ROTARY DEPTH OF GROUT SEAL-----'-TREMiE TYPE TO"BE USED:. a AUGERS {):HOSE <br /> (]AIR SPARGE 13 PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FRE=E-PALE.DiwPTH!13 301 <br /> E7 SOIL BORING E]HAND AUGER GROUT SPECIFICATIONS: "' BOLTED -kAFFIC BOX or it STOVE PIPE <br /> l3 OTHER:��OTHER APPROX.BORING DEPTH . <br /> CONDUCTOR CASING PROPOSE(If YES,list 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 RI=GIUIRE~D.'1NSPECTI01►IS: <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San 3oaquln <br /> County 0 distances,Rules a Regulations,and all applicabie Califo Ea Stake Laws. -ts <br /> Signed x ~v` '"'r` TEtfBlCompany <br /> ��� 1/ Z� 11r� <br /> ILLS Ut�r. Date <br /> Print Name DEP U TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> �* k <br /> C ,Date issued ?p �'"va <br /> Application Accepted By Z <br /> Grout Inspection By Date Z O mal Inspects By <br /> Destruction Inspection By Date <br /> r <br /> '+. <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 'D BY DATIE PERMIT 1 SER=E REQUEST# INVOICE <br /> O1/7 A I3n 36` <br /> C-57� WCC WANEI2 C-57 Letter of Authorizati no sign►permit Erlcro-6chment doc 19/27/04 <br /> E9 :aEvd i'JflE� 'HL�I� ErEtrE89b60L 99 E T60t;18Z/Z0 <br />