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WELL PERMIT APPLICATION FORM <br />SARI JOAQUIN COUNTY pU.6LIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH 5 2) <br />304 E. Weber, <br />nrtockton, CA., <br />{204} 468.3449 <br />SITE <br />MITIGATION <br />UMIT IV <br />MAY 0 9 2003 <br />ENV <br />NO EFUNDABLE PERINrr EXPIRES 1 YEAR FR M D TE ISSUED 1iCetion is made in compliance with San .... <br />tippll�tien is hereby made to San Joaquin County fnr a permit to ConstNct and/or install the work pdde c Health Servicribed. This ces, Environmental Health Division. [_ <br />Assessor's <br />loaquln County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County S t"` 1\+v.\ Zip S ( Pareel# <br />(Uia r , Cross StreetCity I <br />NELLLocation. 4-% Zjp '.Phone# v L` <br />M Address L� Sv - City <br />PROPERTY owner a' .1 r\ v 151 i; <br />Wty��s�=�--Zp 5 ��–L' '--�Pnone# <br />C-57 Contractor L u S` c Ci 14 <br />cam, 4 L �' `` IC d' l`v <br />Phone► 3J <br />ili " 1 •1 <br />Address US CitY,l— <br />Consultant / Sub Contractor Range Section <br />. Y ,Township _ <br />GIS Coerd'inates. X r" <br />' <br />S e t c<°e r 5" ^t u DESTRUCTION (choose type below) <br />WORK TO IE PERFORMED:OVER-AUGER, <br />XNEW WELL / BORING (CPTa SOIL BOR NG # ROPUNCH, HAND -AUGER. OTHER!) p pRESSURE GROUT <br />ji(WELL 4 t�- � Grout Specifications: <br />,Other. <br />I-V <br />TYPE OF WELL <br />INSTALLATION TYPE <br />ji MONITORING <br />tWOLLOW STEM <br />X;EXTRACTiON <br />PAIR HAMMERIORIVEN <br />j] VAPOR <br />p MUD ROTARY <br />AIR SPARGE <br />o PUSH POINT <br />Q SOIL 50RING <br />p HAND AUGER <br />Q OTHER:, ,0 OTHER_ — — <br />_ 5 [ V(f <br />CON5T1zUGTlON SPECIFICATIONS YES NO WELL CASING DIA: <br />CABIN BOREHOLE 5� 2 _ MULTIPPE OF CIASING'. V STSEEL *VC G OTHER: <br />CASING THICKNESS_�T HOSE <br />pEPTH OF GROUT SEAL,_ � 3 TREMIE TYPE TO BE USED' AUGERS p <br />GROUT SEAL PUMPED: $YeS No (N� fi�jt ilU1AX MUM FREEf-FAL DEPTH 1S 30' <br />GROUT SPECIFICATIONS: C �,- BOLTEU <br />TRAFFIC BOX or 0 STOVE PIPE <br />APPROK 60RING DEPTH,_ ` (YE <br />CONDUCTOR CASING PROPOS91 list specifications here)f <br />E01�,_ l <br />�.�T nee�A1TC <br />-rTc nnQ�t�t�S REQUIRE ACCESS OR EiVGPtv/��-r+t^'�eG� tuepl:CTiONS. <br />{VVIF• Vr v••-- <br />CALL THE UNIT IV INSPECTOR 48 WORMNG HOURS IN wovk will be done in accordance with San Joaquin <br />1 hereby certify that 1 have prepared this application and that the <br />atiorls, and all applicable California State Laws. <br />County Ordinances. Rules a d Reg _ l , �,,. � �}f-FJ- Ehg trP. ✓)�,-, <br />11A ^ I// Title/Company ` <br />z <br />Signed x v <br />Print Name <br />owr?S Com= <br />SITE MAP IN UNIT IV RLE, ADDRESS:, <br />WORK PLAN DATED. <br />Date Issued <br />Application Accepted Gy Date S Final Inspection By <br />i <br />Grout Inspection By Hata <br />Desmons <br />COMMENTS I <br />ACCOUNTING ONLY: AID# ` <br />C}iECK 0 RECD t31r DATE <br />PE CODES FEH INFO AMOUNT REMRTED I / <br />C7 <br />zC <br />� � J <br />REQUEST $ <br />3Sa� <br />0 0 1 t\ U9/2 <br />C-57,• WCC WAIVER! C-57 Letter of authorization to sign pertnit� gncraachment oc, <br />:I <br />M <br />