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6 1 <br /> IWELL PERMIT APPLICATION FORM {: .SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber,Third Floor, S*kton, CA., $5202 <br /> - (209) 468-3449 <br /> DATE <br /> NON-REFl7NDASLE PERMIT EXPIRES 1 YFAI2 FRONDATEtSSUED <br />` kpplication Is hereby made to San Joaquin County <br /> t 5 for <br /> and the <br /> coots ct Sari Joaquin'in�my Publthe rk ic Health Sesvibed. This �wo s�Environmental Hii mad6 in ealth IDivl on.�LSan <br /> Joaquin County Development Titie.Chapter Assessor's <br /> �SZu ZS t}-31 <br /> Cross Street Q Clty o�1c��. z€p `I Par�lt� s l <br /> !YELL Location <br /> C4.S L"J. " Zip S �Phnne# _ <br /> PROPERTY Owner Sl.o r.� F f Address RS 61� <br /> c4Phona#i `\\�a 1 Ob <br /> -t <br /> C-67 Pb �l C€ty <br /> C-67 Contrantar Zy 9 <br /> V,''cS p 1'Y'` S'c Cltyrn`�d`I�1� Pt7one#� <br /> Consultant j Sub Contractor ���'�`° i cs'-k Address <br /> Range <br /> GI$Coordinates:X^ <br /> Y ,Township Secctinn <br /> WQFtIf TO BE PERFOR EF1 Q DESTRUCTIOR(clnoosa type below} <br /> a NEW WELL I BORING(CPT,GEOPROBE,.HYDROPUNCH,HAND-AUGER,OTHER*) 1]OVER-BORE <br /> i jj SOIL BORING# a PRESSURE GROUT <br /> Grout Specifications: <br /> CoMMENTs: � a W '\C.T' �- C .� o C- L <br /> TYPE OF WELL INSTALLATION TYPE CoNg TRt3"014 SPECIFICATIONS <br /> MMONITORING 11 HOLLOW STEM DIA.OF BOREHOLE 'MULTIPLE CASINGS?BYES NO WELL CASING DIA <br /> EXTRACTION j]AIR HAMIvIER10RIVEN CASING THICK€�tESS TYPE OF CASING: STEEL 0 PWC. (]OTHER: <br /> n AUGERS 0 NOSE <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USESEAL. <br /> AIR SPARGE [}PUSH'POINT GROUT SEAL PUMPED: Q Yes ji No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30') <br /> 17 SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> [i OTHER: �1 OTHER APPROX.BORING DEPTH_ <br /> []BOLTED TRAFFIC BOX or [j STOVE PETE <br /> ` G NDU TOR CASING pROP05ED? (if YES,list specifications here)= <br /> ' 6,- �C a�[JV SLI vim) O <br /> `GOM4AENT's: <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 /> h <br /> I hereby certify that I have prepared this appticafion and that the work will be done in accorcEance with San,laaquist <br /> County Ordinances,Butes and a utations,and all applicable Catifornia State La'�srs. <br /> C� <br /> Signed x <br /> TFtIalCornpany V <br /> Da <br /> Prim Name v <br /> DEPARTME [T USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> I ,2�• =Date Issued Area <br /> Application Accepted By Date d <br /> Grout{nspectlon 9y Date 3 v,(�nal Inspect€on By <br /> I <br /> Destruction Inspection B Date <br /> COMMENTS i CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFD AMOUNTRE CHECI4# REC'D BY D PERMIT l SERVICE REcQUE$T# INVOICE <br /> C-57_„-_, Wi-WAIVER , C-57 Letter of Authorixation'to. grI t' it—EeZet'dracl�ment doe 9/27/40 <br /> E0 39VJ � 2�DC}ld H1�IA EE0E99t'G0Z, 99 :EI T00Z/8Z/Z0 <br />