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WELLORMIT APPLICATION FOA <br /> RECEV Ef_ MITIGATION <br /> o � SITE <br /> USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> MAY 0 7 2004 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES <br /> 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 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location �Oq W- WGW-1L prv4' S-IT'c*til Assessor's <br /> Cross Street N City Z�, Parcel#" <br /> PROPERTYOwner S-POCIf-"�) 2126#- Address Z2-/=-WeSe-AA�16. city 9To1-C7o-J Zip9S202Phone#(2o1, 73 >_%) <br /> C-57 Contractor_rll S/L�r Address 3p �Z �� �- Cdj� <br /> d `/ ty___ f/p// Lic# /�h # <br /> Consultant/Sub Contractor SC-ccL - Address300h Chy�'o ,A- Lic# Phone#C9r6��/-OfJUJ <br /> GIS Coordinates:X ,Y -Township 1 N Range G tS Section <br /> WORK TO BE PERFORMED: <br /> ,gNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION(choose type below) <br /> D SOIL BORING# D OVER-BORE <br /> WELL#.djd -Y D i .H W-V 1 D PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING D HOLLOW STEM DIA.OF BOREHOLE-9-" MULTIPLE CASINGS?D YES ,$NO WELL CASING DIA: L r/ <br /> D EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS 50,•YO TYPE OF CASING: D STEEL XPVC D OTHER: <br /> D VAPORD MUD ROTARY DEPTH OF GROUT SEAL Y9 REMIE TYPE TO BE USED: E AUGERS [I HOSE <br /> 0 AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: XYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> ]SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: .A,�C 41 Ge m�-i <br /> ]OTHER: n OTHER APPROX.BORING DEPTH S / D BOLTED TRAFFIC BOX or KSTOVE PIPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED? uJ (if YES,list specifications here): <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 /> hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> AgnedX ­F- " / li— Title/Company ` - 3 �Z --J5r%T7- Sec o-.. <br /> 'dnt Name — Data 'r+✓�* ,S,2.a 4 <br /> DEPARTMENT USE ONLY <br /> ,ITE MAP IN UNIT IV FILE, ADDRESS: <br /> iIORK PLAN DATED: f <br /> �Mop#cation Accepted By4 Date lesu "X 7 Arearout Inspection By Date Final Inspection Date <br /> esouction Inspection By Date <br /> DMMENTS/CONDMONS: <br /> \CCOUNTING ONLY: AID# <br /> cerw <br /> -E CODES FEE INFO AMOUNT REMr17ED CHECK# REC' BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Sk7 0 SR# ! c 3 l <br /> -57_ WC--WAIVER— C-57 Letter of Autho za 'o to sign permit_Encroac ment doc_ 9/27/00 <br />