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12/07/2000 10:42 2094683433 FIFTH FLOOR <br /> ) <br /> WELL PERMIT APPLICATION FORM SITE <br /> MI7l6ATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV". <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> i <br /> NON REfUNOABLE PERMR EXPIRES t YEAR FROM DSD <br /> I Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. Ser ices.Envi i 1 made in compliaM�� <br /> poses es q <br /> Joaquin Coun evelopment Tide.Chapter 9-'1115.3 and the Standards of San Joaquin County Pu Uic Health Serv'1�,EndronmePntai�H�eaiN Division. • <br /> City <br /> arO Cross Street ggjl phonw�y ZZ..22r3"- 300 <br /> I YV�LLL A CityJb(rAwtu}'C.I[. LPJ-it-`-`- <br /> I <br /> PROPERTY Own r �, 4-%7v- <br /> C-57 <br /> �1 �'' �"� _'� IJUI '�O�Phone# IfeoD�Y_zA-YY33 <br /> C-$t Contractor Adareaa 4-%7v Mtr�awLa. city lP9�Qfi �-- <br /> Perone# <br /> Consultant/Sub Contractor &dr U Addfessy2iN T(1�{• �n _City IAV ��� <br /> y < ,Township, <br /> Range Section <br /> GIS Coofdlnatea:X <br /> WORK TO BE PERFORMED: n DESTRUCTION(ch00se type below) <br /> p NEW WELL I BORING(CPT,PEOPROBE.HYDROPUNCH.HAND AUGER,OTHER) 0 OVER-80RE <br /> `��O,SOILBORING# er " m6A-) PRESSURE GROUT <br /> WELL# Grout-other. <br /> Comm <br /> TYPE OF WELL INGTe�t�-TION TYPE CONSTRUCTION SPECIFICATIONS <br /> E MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULE OACASING: a STEEL 0 NO P C 1)OTH R: <br /> EXTRACTION O AIR HAMMERIDRNEN CASING THICKNESS <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 <br /> 0 AIR SPARGE O PUSH POINT ') <br /> 1t SOIL BORING - HAND AUGER GROUT SPECIf1CAT10NS: <br /> (_ APPROX.BORING DEPTH.u BOLTEO TRAFFIC BOX or []STOVE PIPE <br /> 0 OTHER: OOTHER CONDUCTOR CASING PROPOSED. (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 REQUIRED INSPECTIONS. <br /> I hereby cerci at I h� ave prelparetl th' 01catioo`aand that <br /> t e work <br /> Will <br /> be done In ia State Laws, accordance with San Joaquin <br /> County O ' ance;//Ru)es and Reg A - -S <br /> �ji' Tloe/Company H�T'� _ U I IrD] <br /> Signed x - - <br /> Date 1 T�0 Z� <br /> Print Name pEpARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> Il <br /> WORK PLAN DATED: <br /> ,7VA101 Date IssuedI �.n �' \ Area - v <br /> Application Accepted By Dat b Final InsPectOn BV—: r <br /> Grout Inspection <br /> BY (� <br /> Destruction Inspection By <br /> Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDS <br /> RECD BY DATE PERMrtrSERVICE REQUEST 11 INVOICE <br /> PE CODES FEE INFO AMOUNTREMIRED CHECK11 l- -D � <br /> 360 �11 4- 5 z3 �? <br /> C-57, WC_WAIVER, C-57 Letter of authorization to sign permit,Encroachment doe_ 9/27/00 <br /> t <br />