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Fill F <br /> WELL PERMIT APPLICATION FORM 5 <br /> SITE <br /> - MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> DEC 0 7 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> Tri (209) 468-3449 OFF/ "Sfofo PRc��'u <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> TAT - R1W - <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 /> C /� ,y I Assessors <br /> WELL Location 51-5 PDCI C-<_ /�Ve Cross Street t1TS City 5-Cortcto-1 Zip 520 Parcel# 108'/60-0/ <br /> Sart 1-0 V% <br /> PROPERTYOwner felt•a (-p11'rraP Address SaYn Ie/. City Zip Phone#20QA5 V_-W39 <br /> C-57 Contractor C Address 100 5th StPee t CityefoTZip $6 is#12ZQ*hone# 6 77-- Ot <br /> Consultant/Sub Contractor Er)VIf0rIr4VAt0ll�&tA_ddress j00eAt9�d.Gity C4U,#A063y&hone# -oS <br /> GIs Coordinates:X ,Y .Township / Range Section <br /> WORK TO BE PE ED: <br /> gNEW WELL/ ORING CPT,GEOPROBE,HYDROPUNHAND-ALIGER,OTHER') 0 DESTRUCTION(choose type below) <br /> /- SOIL BORING# D OVER-BORE <br /> WELL# V PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE B" MULTIPLE CASINGS?BYES 0 NO WELL CASING DIA:_ <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> U AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> R'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER: 0 OTHER APPROX.BORING DEPTH Peet- 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CON UCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: rVC4 <br /> NOTE: OF ITE 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 O 'nances, Rules prtd Regulations, and all applicable California <br /> �State <br /> ,"Laws.. <br /> Signed z Title/Company 4 <br /> 7Wf / CMitlfitlsn,n�.lPw.. <br /> Print Name Date 17- <br /> DEPARTMENT USE <br /> EEiONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: pyo/ <br /> Application Accepted By Date Issued l Z - — 0 / Area Q 6 a / <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 350 89 / 2 DOZ ZI'Z- <br /> C-57_ WC=WAIVER ^ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/27/00 <br />