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Y <br /> WELL PERMIT APPLICATION FORM SITE <br /> 2001 MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> r,L,\LTHENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> PEiP Ii i/SERVICES 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> 05-Zp (209) 468-3449 <br /> Ureby NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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.y3�pand the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location I/l�DY�kwaq "LI__ gross Street_ 9/ _City CA ZAP 3�I� Parcell <br /> PROPERTY Owner � 'Lf� I�-t 1Df5t1 Address_LNQ I&QL=LI1--C'� �A Zip s Phone# Z `� S 2- <br /> C-57 <br /> 0y <br /> C-57 Contractor_(<< I fMC1 r/�StpR�,tFt$,ddress 7anl AAAfk F (� City Q d(P(1 Lip 911001 Lic# 3 4 Phone# s3 qq-903 <br /> Consultant I Sub Contractor Address— C;ty`l ' Lic# Phone# <br /> GIS Coordinates:X_ <br /> Y ,Township 12S Range ( _ Section 2-q <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> )(NEW WELL/BORING(CPT,GEOPROBE,F{YDROPUNCH.HAND AUGER,OTHER'} (]OVER-BORE <br /> (]SOIL BORING# []PRESSURE GROUT <br /> WELL# Of3 -Z(p� <br /> Grout Specifications: <br /> 'Other: <br /> COMNIENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE -# � MULTIPLE CASINGS?[]YES NO WELL CASING DIA:__7-- XIA <br /> %[]EXTRACTION (]AIR HAMMER/DRIVEN CASING THICKNESS Snc�dkl( y0 TYPE OF CASING: []STEEL 'PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL 2D ' TREMIE TYPE TO BE USED: o AUGERS []HOSE <br /> []AIR SPARGE (]PUSH POINT GROUT SEAL PUMPED: []Yes JgNo �.NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> []SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: Ce.16#1t <br /> []OTHER: []OTHER APPROX.BORING DEPTH "'SO Y1• BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' ances�Rulesss an Regulations,and all applicable California State Law/s. / <br /> 1 ,�/ �.!� Title/Company /L/IrnJr'EnGe cf` ��� <br /> Signed x ��/— <br /> Print Name �l Date <br /> �l�.l l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNITU-FILE,ADDRESS; <br /> WORK PLAN DATED: <br /> Date Issued .0- <br /> s © Area <br /> Application Accepted By Date 2 2 <br /> Grout Inspection By ` �14l Date C Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> EACCOUNTING ONLY: AID# <br /> FEE INFO AMOUNT REMfrTED CHECK# kOE PERMIT!SERVICE REQUEST# INVOICE, oG s of o 5 z Y <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_. 9/27/04 <br /> CC) =r,"- _ rr.L�� Hl-I: �C7EA9G60Z 9F :GJZ T00?/LO/,0 <br />