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WELL PERMIT ,APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third FFloor, <br />Stockton, CA., 95202 <br />SITE <br />MITIGATION <br />UNIT IV <br />MAY 0 9 2003 <br />NO <br />-REFUNDABLE PERMrr EXPIRES 1 YEAR FR M D TE ISSUED lication is madZ'iM` `ompliance with San, E_ <br />�ppllcaGen is hereby made to San Joaquin Coanty fora permit to construct andlor install the work described. This a p <br />Assessors 1 Ci c is ti <br />loaquln County Development Title, Chapter 9-1115.3 and %me Standards of San Joaquin County Public Health tSery��. Eng �ror'me rte# ItR 0 n <br />OV ) e . city 5'-ta". Zip <br />Cross Street d r r <br />HELL Location Co( � 1 City 5 �� tc zip—— <br />71 <br />PhoneR Zoe DD <br />c 'A ( l LAddress ; G <br />PROPERTY Owner ;Ok tN 4 - ti ° i 5 7 rt /� ? t Pnana# 4 8 ` <br />Gty Zip L'e#�� <br />C-57 Contractor L k 7 ca �� l I I° dtes9 O ,, r /, /" t i <br />5 <br />U �{ Cn ,h. c: Address <br />� e Y ��YS - City,Lie� 3 r cis t Phone;;'_SS 3---- � � 4 — � 0U <br />Consultant / Sub Contractor Range Section <br />. Y .Township \ <br />GIS Coordinates; X <br />(-S<2 c e..c aye �r ��`' e / <br />yy��IU3E PERFORMED: [] pESTRUCTION (choose type below) <br />i7OVER•BORE <br />L I BORING (CPT, GEOPROBE. HYDROPUNCH, HANG -AUGER, OTHER) `✓ , c, �e i iS p PRESSURE GROUT <br />� SOIL BORE Gal: _ � A. f� �. <br />W ELL f� ( <br />Grout Spe/C natio <br />'other: r u, c w t <br />COMMENTS: I,'�z w ( h , • - w � � �{ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION sPECIFICATI MULTIPLE CASINGS? Q YES to NO WELL CASING DIA. <br />,"ONITORING JWOLLOW STEM DIA. OF BOREHOLE — <br />STSEL PVC Q O1HER: <br />TYPE OF CASING: Q � HOSE <br />1] EXTRACTION El AIR HAMMEFUDRIVEN CASINGTHICKNSSS� o rREMIE.��E TO 6E USED' AUGERS (i <br />U VAPOR p MUD ROTARY OVTH OF GROUT SEAL: 2— <br />SPARGE (] PUSH POINT GROUT SEAL PUMPED: Yes Q No (NOTE; MAXIMUM FREE -FALL DEPTH IS 30' <br />n AIRY w t S <br />HAND AUGER GROUT SPECIFfCATIONS: STOVEPIPE <br />() SOIL BORING d APPROX 80R1NG OEPTH U OLTED TRAFFIC 80X or <br />OTHER_ --� if YES, lint specifications here):, <br />Q OTHER'' CONDUCTOR CASIN )g PROPOSED?� <br />I i Y 1 i D J/ 1 ✓'' ti —} C L ✓ Ire <br />*COMMENTS: ' ' <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OIRENCROACHMENT INSPECTION'S <br />. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADV done in accordance with San Joaquin <br />I hereby certify that I have prepared this application and that the work will be do <br />Re <br />Signed and all applicable California State Laws. <br />County Ordif3artGgs, Rules an <br />C— <br />Signed <br />Print N <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issues <br />Application Accepted BY Date Final Inspection13Y <br />Grout Inspection By Date <br />Destruction Inspacticn BY <br />COMMENTS I CONDMONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES <br />Fa?E tpFa AMOUNT REMT TE0 I CHECKS <br />C-57: WCC WAIVER: <br />7- <br />0 <br />RECO By DATE PERMIT I SERVICE REpUHST # INVOICE <br />,mc> i-C(I I Dkc/ C/ - ,j 9 <br />oc, <br />C-57 Letter of authorization to sign permit: Ent:r <br />k�. <br />J <br />