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DEC 0 7 2000 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> WELL PERMIT APPLICATION FORM - SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH MVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <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 r lade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1116.3 and tt.e Standards of San Joaquin County Public Health Services.Enviror rental Health Division. <br /> rr � Assessor's <br /> WELL Location_ R���(�/�.$9t�� G.�Cross Street .t/ City P-41— Zip-3.5jOS Parcel# 33-5 <br /> sM" s� CitS42y Pho <br /> PROPERTY OwnerPddn ne# �0 N�8 SS <br /> '' ff �.'"�� D <br /> C-57 Contractor c Adcress T�� .!/icy god Dl CltyyS6GKt, Zip_hZl6CLL.c#6jZk &none# <br /> ConsultantISub Contractor fQ3 (U Address1:1 IQ Sf CltVS a Liz# Phone#�$$� _. <br /> GIS Coorcinates:X—....—.Y_,Township Zk) Range Seatcr �Z <br /> PERFORMED:JET <br /> I BCRIP (CP-,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# a OVER-BORE <br /> _ Q WELL ftp/ 0 PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE,OF WELL INST j,LATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ff'MONrrORING E<OLLCW STEM DIA OF BOREHOLE__MULTIPLE CASINGS?0 YES ONO VlELL CASING DIA: Z <br /> f1 EXTRACT ON r,AIR HAMMER'DRIV=N CASING THICKNESS geA 4JO TYPE OF CASING: 0 STEEL 13,15-VC 0 OTHER: <br /> 11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 31 - TREMIE TY0E TO BE USED: 91"ERS p HOSE <br /> p AIR,SPARGE Il BUSH POINT GROUT SEAL PUb1PED: es ONO (NO : MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Xflftl eftw�JT <br /> 13 OTHER: 0 OTHER A=PRCX.BORING DE.=TH �OLTED TRAFFIC BOX or 0 STOPS PIPE <br /> CONDUCTOB C ING PROPOSEP? (SYE3,list spec flcaY s here). , <br /> •CCMMENTS: ��+ ft �I j.m 1A 14 <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 Lhaw prepared this applicat nd that the work will be done in accordance with San Joaquin <br /> County Ordi s,R and Regulation nd all applicable California State Laws. <br /> Signed x Tit!e /Company n 7J <br /> --- -- --- I1 -- <br /> Print Name <br /> A-1 Date I? l l LTr� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued v Area <br /> Crout Inspection By Date Final Inspec ion By Date <br /> Destruction Inspecticn By Date <br /> COMMENTS/CONDITIONS. <br /> ACCOUNTING ONLY. AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK>YREC'D BY DOTE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 S0 1 i " <br /> C-57— WC -WAIVER- C-57 Letter of Authori(zatioV6 sign permit_Encroachment doc_ 9/27/00 <br />