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111 412000 17: 35 20946830'9 FIFTH FLOOR PAGE 04 <br /> G� WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> v ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ` 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This applioatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environme A I esslth Division. <br /> o s <br /> / Cross Street City 0 Zip 5�� Parcel# 7- I-S 3 <br /> WELL Location f w I h v� C r <br /> /I Y uCn3 >n !� City IAN tf.4&.Si�Zip e/y/US phone#_ <br /> PROPERTY Owner O n fa • 1 i , Address <br /> C-57 Contractor r c'5 ibh <br /> sic t+-nI1 K�Address�'f G�l� �5 fi City ` Zp` ' -V Ljc#14/ iib'7 Phone# 7'4 S) <br /> Consultant/Sub Contractor J J �N v:ry�►^ °h�r� Address­,—�1 ��✓ ��y�Cib�Lvp tiw Lic#_Z 9�6d Phon /' � lb�� <br /> GIS Coordinates'X <br /> Y Township.Range Section <br /> WO K TO BE PERFORMED: DESTRUCTION(Choose type below) <br /> EW WELL BORING(CPT,GEOPROSE,HYDROPUNCH,HAND AUGER,OTHER-) 0 OVER-BORE <br /> ,.'SOIL BORING#F <br /> I]WELL# Q PRESSURE GROUT <br /> Grout Specltications: <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRU ION SPECIFICATIONS <br /> MONITORING I]HOLLOW STEM DIA_OF BOR HOLE -;N(k MULTIPLE CASINGS?I]YES gNO WELL CASING DIA:_j/A <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THI KNESS /V._TYPE OF CASING: a STEEL (]PVC n OTHER: 41A- <br /> VAPOR Q MUD ROTARY DEPTH OF G ROUT SEAL-�0 ty 'tTREMIE TYPE TO BE USED: o AUGERS o HOSE <br /> p AIR SPARGE WUSH POINT GROUTS PUMPED: p Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING 0 HAND AUGER GROUT SPE IFICATIONS; rpm e i t - &;M Vn t-- <br /> 0 <br /> t0 OTHER: OTHER„ APPROX.B RING DEPTH ^-3O r.,Y0 17 BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> CONDUCTO CASING PROPOSED? 1V (if YES,list specifications here): <br /> " 4a <br /> COMMENTS- N ��✓ hM <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKIN13 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 ordinaMes, Rules and Regulations, and all applicable California State Laws/. <br /> Signed x TitletCompany St N �� (�' If ff, 61 v,t <br /> Print Name 1 r l !A �f" * Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: J� <br /> Application Accepted 8Y Date Issued-11�/dy Area_ <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMrr'TED I CHECK V RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> fill <br /> 1,2a al <br /> C-57 WC -WAIVER C-57 Letter of uthorization to Sign permit Encroachment doc 9/27/00 <br />