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WELLI-'ERMIT APPLICATION F(YRM SITE <br /> MITIGATION <br /> SAN <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> SEP 1 9 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> Ell �,� r,�i rltp�fH <br /> r <br /> RV C1 S NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application 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.Environmental Health Division. <br /> �rQ� �r�� /.'- Assessor's t, <br /> WELL Location /U//pri1�7�'7�/ ross Street City l �B•!°/��LZip Parcel# ��� O �U <br /> PROPERTYOwner �n,/P� � Address City Zip Phone# <br /> C-57 Contractor/4 /Zfr7�'� Address 32 .f /`i� .----Cit y_L Zi Z Lic#j� Phone# 6 q^�7� <br /> Consultant 1 Sub Contractor 60/Q-Si�lj i ress�l �6 /� City_�d.0 llf Lic# Phone# 6 'W1 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION(choose type below) <br /> Q SOIL BORING# Q OVER-BORE <br /> Q WELL# RESSURE GROUT <br /> `Other Grout Specifications: ' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?n YES []NO WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> (]OTHER: Q OTHER APPROX.BORING DEPTH jl BOLTED TRAFFIC BOX or []STOVEPIPE <br /> G CONDUCTOR CASI PROPOSED? if YES,list specifications here): <br /> 'COMMENTS: Iftw.�9N � =�a;�Tr <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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance Rules nd Regulations, and all applicable California State Laws. <br /> Signed x TitlelCompanyGO� �/1� 70/1/'� <br /> ,g!;��;��DE� ARTM Print Name �li//� Date <br /> ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C <br /> Ap iicaab�n��A,,� pied By Date Issued b� AreafS i �� <br /> GrCwilfispecTioy � Date ► Final Inspection By Date <br /> Destruction Inspection By Date 7 6 1 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> al-? - 02- �,o /79 /J.IG 6► SR# 00 01- <br /> C-5T­ <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> 70 99hd a00-1A H13IA CEVE89VGOZ SS:EZ 100Z/E7,/E0 <br />