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WELL'PERMIT APPLICATION Fw2M SITE <br /> MITIGATION <br /> SAN JOAQUIN 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 4 YEAR FROM DATE 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 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> - / Assessor's <br /> WELL Location Z227/V ✓;' '0'0' •sf Cross Street Ci zip�arcel# <br /> PROPERTY Owner /� Address ZBao W' IVa C; � Zip_tPhhoone# / <br /> Lic#s.e��f <br /> C-57 Contractor Addres <br /> Consultant/Sub ContractorAWS77 Address 7.f7 City20-4-9-- LickPhone <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 'DESTRUCTION(choose type below) <br /> SOIL BORING# a OVER-BORE <br /> Q WELL# PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?Q YES 0 NO WELL CASING DIA: <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL [IPVC []OTHER: <br /> VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> AIR SPARGE PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> Q OTHER: Q OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or a STOVE PIPE <br /> ,,���� CO,gN�UCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: ,/lo^iWAL1 lelAu,< rVI VV — <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 pre ared this application and that the work will be done in accordance with SalohMquin <br /> County Ord' nes,5dles an egulat' , and all applicable California State Laws. C36.6Signed x Title/Company <br /> Print Name Date 5rn- 0 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> L.I.S <br /> WORK PLAN DATED: <br /> Application Accepted By f Or-� Date Issued Z 3 D Area <br /> Grout Inspection By `�w- Date �{ 77. d) Final Inspection By Dater D/ <br /> Destruction Inspection By Date <br /> COMMENTS ICON DITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED "CHECK# REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 .oG � o o �.s"93 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />