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05-18-2201 07:44AM FROM TO 191663588e15 !'.'d� <br /> WELL HERMIT APPLICATION FOOROM SITE <br /> MITIGATION <br /> SAN JOA�QUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.!Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-RE=FUNDABLE PE mrr EXPIRE5J-YEAR FROM DATE ISSUED <br /> ApplicaCon is hereby made to San Joaquln county fdr a permit to construct and/or install the work described. This application i5 made in compliance with San <br /> Joaquin County Deveto me Ti le,Cha t r i=ra <br /> a Standards of San Joaquin County Public Health Services,Environmental Health Dlvislon. <br /> �1 Assessor's <br /> WELL Location x ss Street City Zip P <br /> PROPERTY Owner m J 6,.rt Address�l l� 6 I 1{I Ei Ciry "j r Zip %S^ZYOPhone# <br /> cs�ycY65- Z S 3/ —S6cr <br /> `fi <br /> C-57 Contractor Add�ress '� <br /> Consultant 1 Sub Contractor t,'�2 �r�r�z(� _ Address Z 761 pl-c 1pe6t pc-,� pi Cityf�c clic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PE MED: <br /> cey 1]DESTRUCTION(choose type below)NEW WL O NG H,HAND-AUGER,OTHER-)�ONC <br /> .ArSOILBORING#! a OVER-SORE <br /> p PRESSURE GROUT <br /> DWELL# <br /> 'cher. (� Grout 5pecittcatlons: ft. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTR 71 N SPECIFICATIONS <br /> a MONITORING 13 HOLLOW STEIN DIA,OF BOREHOLE MULTIPLE CASINGS? Ll YES ONO WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/IDRIVEN, CASING THICKNESS TYPE OF CASING: a STEEL II PVC p OTHER, <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS n HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAT.PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3o') <br /> (SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER: THER �Vj `,'�-',APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE;PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,fist 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 /> I hereby certify that I have prepared toffs application and that the work will be done in accordance with San.Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> 5iprsadx 1. <br /> 4,1 !�� � �%v`-�.' Title/Company,&f:t.)n &yL Ic(,✓ 4 <br /> Print NameI s✓ . - VI �� Date <br /> 1DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRES k t JM <br /> WORK PLAN DATED: <br /> Appiicatlon Accepted By I' Date Issued�,.,��_ -S t Area <br /> Grout Inspection By 10 <br /> Date Final Inspection <br /> Destruction'inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY. AID# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK t# RECD BY DATEPERtNfT 1 SERVICE REQUEST# INVOICE <br /> C-67 WC -WAIVE;Z G-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />