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06/14/2001 10:13 2094683433 rirlH rLUUK UT— <br />u� <br />WELL PERMIT APPLlCATION FOFS <br />SAN JOAQUIN COUNTY HEALTHIC HEALTH SERVICES <br />ENVIRONMENTALDIVISION (PHS EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ton is <br />Application Is hereby ma <br />de to Sanment Title, (Chapter 9-1115.3 nd.the Standards of San Joaquuiinl County Pubs c Heethe work a th Service. This s,,EEnvironmerM2ntal Health e in compliance with San <br />JoaGuln CountyDevejlo�j�j` Assessors <br />toss Stree My <br />WELL Location <br />7�0I Addn:ss <br />PROPERTY Owner Phone# <br />C-57 Contractor <br />Phone# <br />Jr%F C <br />Gonsultarrt /Sub Contractor Address <br />' y Section <br />GIS Coordinates: X <br />. Y___.. Township ,�'� _Range , <br />WORK TOBE PERFORMED: DESTRUCTION (choose type below) W <br />Q NEW WELL / BORING ( CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER`) a OVER -BORE <br />0 SOIL BORING # U n PRESSURE GROUT <br />V W E LL 911:14 <br />'Grout Specifications: vil <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />MONITORING <br />HOLLOW STEM <br />I7 EXTRACTION <br />a AIR HAMMERIDRIVEN <br />0 VAPOR <br />a MUD ROTARY <br />0 AIR SPARGE o PUSH POINT <br />n SOIL BORING U HAND AUGER <br />0 OTHER:_ a OTHER <br />- <br />-COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OP BOREHOLE_ MULTIPLE CASINGS? 0 YES jJ NO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: (] STEEL Q PVC [I OTHER: <br />OEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS o HOSE <br />GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30) <br />GROUT SPECIFICATIONS: STOVE PIPE <br />APPROX. BORING DEPTH p BOLTED TRAFFIC BOX or Q <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications hare): <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 prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules a egulations, and all applicable Californi tate �a s. <br />x1 f/�j21 C✓�% TitlelCompany <br />Signed 16 ©1 <br />Print Name G� _ / �)L` Date <br />r,�owcTlu�lUT t TSF_ ONLY <br />SITE MAP IN UNIT IV FILE, ADD <br />WORK PLAN DATED: z � ' <br />Area <br />Date Issued <br />Application Accepted B 15 <br />Date Final Inspection By Date_. <br />Grout Inspection By <br />Date <br />Destruction Inspection By <br />COMMENTS I CONDMIONS: <br />ACCOUNTING ONLY: —Al D# r <br />PERMIT / SERVICE REQUEST # INVOICE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ��, S� <br />9/27/CJ <br />C-57 WC -WAIVER C-57 Letter of AuthorizotIon to sign permit nc c .en oc� <br />