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. I a <br /> I <br /> �a WELL PERMIT APPLICATION FOFA SITE <br /> MITIGATION <br /> „0�a�i`�y�, U��O JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 0 �0� 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> O� (209) 468-3449 <br /> O NON-REFUNDABLE PERMIT EXPIRES 1 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 andtheStandards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor <br /> WELL Locational �(u2.7>.( W�SII7 (QAIE Cross Street A/I T/4iE_City d Zip zds Parcel# /0 -ft-0i <br /> PROPERTY Owner) `�IITR�ut N t�1�5 Address__--�iCrt� City Zip Phone# 97& 'Q2- o <br /> 1 II I'' �i <br /> C-57 ContractorW -r 4AZWIAT Address32M t(i?-� 1�/ Q City—cb Zip Uc# LL�Phone#&b W-8%(.3' <br /> Consultant/Sub ContractorAA*444Lb L-•�/i4L��IhC�1M��Address i't• �I�'SAV gid✓ City.STO(k Lic# Phone# 47-(aol� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W K TO BE P ED: <br /> EW WELL BORIN (CPT,G PROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> OIL BORING# R-B RE <br /> a WELL# RESSURE GIRD <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS <br /> a MONITORING HOLLOW STEM DIA.OF BOREHOLE 3 T MULTIPLE CASINGS?p YES �fNO WELL CASING DIA:_ <br /> G EXTRACTION G AIR HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING: U STEEL Q PVC_`0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL7o/SUkfl� TREMIE PE TO BE USED: O<UGERS a HOSE <br /> a AIAIJR SPARGE O PUSH POINT GROUT SEAL PUMPED: Qfes p No (NOTE: 4AXIMUM FREE-FALL DEPTH IS 30') <br /> VISOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �O12'tLR� 1�N^'FN� <br /> OTHER: p OTHER APPROX.BORING DEPTH 15"116 01a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS:^I Bdeld/ -S - <br /> NOTE: <br /> S -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 c ify that I ha a prepared this application and that the work will be don in accordance with San Joaquin <br /> County rdin n�,e Ru es and Regulations, and all applicable California State Laws. <br /> Signedx COY/1 -� _Title/Company5 �} •� a l� '�i� 'u� 4e <br /> - <br /> Pdnt Name 1"AU L- I �"��$0 1 D to ((�27 d <br /> DEPARTMENT USE ONLY —T <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 80/ G✓4..Z;f Lo, — A S S S IMQK I �l^� <br /> WORK PLAN DATED: <br /> Application Accepted By ,C ^' U•� Date Issued / D D Area O 7 <br /> Grout Inspeclion By Y Date Final Inspection By Date <br /> Destruction Inspection By I w.s� �/�. Date /?,� y'�01��� <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_,Encroachment doc_ 9/27/00 <br />