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05/21/2001 09:07 20946834?^ FIFTH FLOOR PAGE 03 <br /> r <br /> P <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN aOAQU1N 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-REFUNDABLE PERMIT EXPIRES 1 YEAt~:FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to Construct andlor install the work described. This 8PPGl tion is made in compliance with S-- <br /> ;Upper <br /> an � <br /> Joaquin County Development Title,C pter 3-1115.5 and the Standards of San Joaquin County Public Health Services,EnvironmenAssessor's ll�Health Division. <br /> -. � Yr _Parfet#, <br /> Cross Street ItY P <br /> yVEtt Location � - Ale <br /> Aleal ip Ptrone# <br /> PROPERTY Owner Address .-C�e. �7� <br /> City �p�iC4'�'�rNhar,e# +�a"(1' <br /> C-67 Contracror Address — f � <br /> ^ � <br /> Consultant 1 Sub Contractor A 6 1� Address Phone# <br /> GIS Coordinates:K_ <br /> TownsMIP Range Section_ <br /> W TO Be PERFORMED: o DESTRUCTION(choose type below) <br /> EW WELL <br /> 1 BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AtJGEE2,Orl{ER•) I Q OVER-SORE <br /> p SOIL BORING# d PRESSURE GROUT f <br /> Q WELL# Grout Specifications: ' <br /> *Other- <br /> COMMENTS; <br /> TYPE OF VVELL INSTRLIJ#TION TYPE CONSTRUCTION SPECIFICATIONM��pLE CASINGS?0 YtS� WELL CASING DIA <br /> D MONITORING 13 HOLLOW STEM DIA.012 BOREHO VC I]OTHER <br /> TYPE OF CASING, (]STEEL HOSE <br /> Q EXTRACTION n AIR HAMMERtORIVEN CASING THICKNESS —TREMII=TYPE TO BE USED: �UGERS Q <br /> tl VAPOR Q MUD ROTARY DEPTH OF GROUT SFJ41 <br /> AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: [I Yes No (NOT : MAXIMUM FREE-FAIL DEPTH IS 30'} <br /> U 50IL BORING Q HAND AUGER GROUT . oRi ICATtONS= STOVE PIPE <br /> APPROX.BORING DEPTH OLTED TRAFFIC SOX Of Q <br /> Q OTHER: U OTHER , if YES,list speeificadvns here)- <br /> ��QQ COND TOR CASING PQ POSED. <br /> "COMMENTS: YZ`IG�YI (1`i ► <br /> NOTE: 0FFSITE BORINGS REQUIRE ACCESS OR E CHM T PERMITSNSPEc ONS. <br /> Cps,L;HF UNIT{V INSPECTOR 48 WORKING HOURS IN AAVAN FOR AL <br /> I herebycertify that I have prepared this application and'th LIQ California lState�wI be done ln accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable <br /> Y�-1 'TitielcompanY �7 [ <br /> 21 <br /> Signed x S�r <br /> (�� Pate <br /> Print Name l-•17TH DEPARTMENT USE ONLY <br /> r <br /> SITE MAP IN UNrf IV FILE,ADDRESS ` <br /> WORK PLAN DATED: !jo <br /> Area_ <br /> r [A� Date Issued <br /> Application Accepted Sy Date, �� <br /> Date Finai Inspection By <br /> i- Grout Inspection By Mate <br /> Destruction Inspection 8y <br /> COMMENTS 1 COMI)fl ION5: f S f drf� <br /> i <br /> f ACCOUNTING ONLY: AID# <br /> G 8Y PA ITTEPERMIT l SERVICF-rREQUFST# INVOICE <br /> ECK# <br /> PE CODES FEE INFU AMOUNT REM"-MD CHQ !moi <br /> � 9!27/00 <br /> C-57 WC�WATVER_ C-57 Letter of Autht i is t sign permit Encroachment doc <br />