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WELL IFERMIT APPLICATION FOR`R�H <br /> SITE <br /> �� MITIGATION <br /> Y. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> \ ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> O2 304 E. Weber, Third Floor, Stockton, CA., 35202 r., <br /> (209) 468-3449 C I L \' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> >pplication 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 /> Assessor's LZ 3 00 1 <br /> � i� <br /> NELL Location � '�� n �j Cross Street 05c,7,r City lr\�,`C�_c n. Zip Parcel# 1 <br /> PROPERTY Owner��,: Ls•. Address �Oy � ��j-LZ, City .c Zipr1 S3�b Phone# <br /> `''�`�l `12 vr1v� <br /> C u7 Contractor °�`a 1 D tL+��� t� Address Q© `r�J'Y- '��� City=Sti�' Zip Lic# Phone# <br /> Consultant/Sub Contractorc'a \,4 �: �o y—�'-C�`�Address L'1�l l 1 S�. City c# Phone#SZ'i <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 11 SOIL BORING# it OVER-BORE <br /> JJWELL# h,\,. �\<\3 Q PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: 5 U� Srk�Q\c�,., t_ t\ r� 1nJ Cts `��.c�L�d 5 e(21r.T� S IZ of 3 <br /> TYPE-OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> &MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES ONO WELL CASING DIA: <br /> Q EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC. I]OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED:. 11 AUGERS HOSE <br /> p AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30) <br /> p SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS: <br /> []OTHER: I]OTHER APPROX.BORING DEPTH . U BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If(Y�ES,list specifications here): <br /> *COMMENTS: v s .�1 R \��9 Q `f (%Y� e tY� `F t 2:R <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin s,Ru s ad R g lations,and all applicable California State Laws. r� <br /> Signed x t Trtle/Company �l`,32 1 SCi <br /> Print NameQ_CA-•�,\.& 1�C��c,� rr'<� Date ` �--- <br /> V <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: !? <br /> Application Accepted By ' Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date 47T_ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 -7 AL-1 <br /> C-57^ WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 4/27/00 <br /> 60 3Jtid N00-ij HlAI.9 EEtbE89b60Z 99:ET T.RR7./R7./7R <br />