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PERMIT APPLICATION FOWM SITE <br /> jj WELL MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 02 APR -8 PM 1: 18 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 'vFeR EReM!}ATE 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 9-1,1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Division. <br /> s <br /> r 1� Cross Street City���pi;2—Z1P�Parcel# D 5- og0' <br /> WELL Locatlon n n A <br /> `�rod� ress �9u1 �i�x��V1f6(1 Ci ZipPhone# - iJ <br /> PROPERTY O``wnte_1 i <br /> C-57 Contra <br /> cthl� �Y��Y'� v► l Address _ f�P3�L u�hon `9�t <br /> Gress C1tyi�=Uc# Phon <br /> 1—Ou 6D <br /> Consultant/Sub Contractor <br /> EtM <br /> Range Section <br /> GIS Coordinates:X <br /> Y ,Township <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> Q NEW WELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q Q OVER-BORE <br /> Q SOIL BORING# idM—W _3 Q PRESSURE GROUT <br /> ;WELL Grout Specifications: <br /> •Other. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONSPECIFICATIONS <br /> IONfTORING �Q90LLOW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?Q YES Q NO WELL CASING DIA: <br /> TYPE OF CASING: Q STEEL VC Q OTHER: <br /> Q EXTRACTION Q AIR HAMMEWDRNEN CASING THICKNESS TREMIE TYPE TO BE USED:-�kAUGERS Q HOSE <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: 1]OTHER APPROX.BORING DEPTH Q <br /> 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County ordiqances, Rules egulations,and all applicable California State Laws. i <br /> S1l x Titie/Company <br /> Date <br /> Pri"t"a"1e DEPARTMENT USE ONLY <br /> SITE MAP IN UNiT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued r <br /> �S�o-z , tvP o� <br /> Application Accepted By wi - <br /> Grout Inspection BY <br /> Date Final inspection By Date---- <br /> Deouction Inspection B Date <br /> COMMENTS/CONDITIONS• <br /> F3'5'b <br /> COUNTING ONLY: IZAID# cer�eCODES FEEINFNT REMRTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> r a-oi b <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doe 9/27/00 <br />