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KIA <br />ORIGNAL <br />WELL PERMIT APPLICATION FORM SITE <br />TION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT MITIGATION <br />APR 13 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />IV <br />ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202/CDS <br />PERMIT/SERVICES (209) 468-3449 d <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 />Assessor's <br />WELL Location � w — Cros'sJStreet /� City5 � "��� �, ZiP 3 Parcel# o <br />PROPERTY Owne 1-1 1-" Address &n— N ' �'D �", C/,itV� cr-^ Zip'F hone# O/3 -7—/o --s 1 6 <br />C-57 Contractor VVf-3 / <br />Consultant/ Sub Contractor! <br />GIS Coordinates: X <br />K TO BE PERFORMED: <br />EW WELL / BORING (CPT <br />'Other: <br />COMMENTS: /J//,011 <br />OririrPsc <br />Y Township <br />, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />0 SOIL BORING # <br />&WELL # g4,11,ef 11A1 <br />Grout Spe, <br />Range <br />#�`� r / 1FJhone# <br />'717V / 7� <br />Phone# 7 tcxJb C\R <br />Secti <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />i <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />J MONITORING POLLOW STEM DIA. OF BOREHOLE ""o'PJLTIPLE CASINGS? 0 YES ,24O WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS )jA- TYPE OF CASING: 0 STEEL c 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-14�10�' TREMIE TYPE TO BE USED:__eAGGERS 0 HOSE <br />0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: jKes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS- ��� 6 <br />0 OTHER:__G OTHER APPROX. BORING DEPLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMENTS: IV100 1 <br />NOTF- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL RtUUIKtu Irvartt, i 1UN0. <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 and Regulations, and all applicable California State Laws. / <br />Signed xTitle/Company <br />Print <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS- 54 <br />WORK PLAN DATED:��- <br />Application Accepted By Date Issued4�6 <br />Grout Inspection By Date Final Inspection By <br />Destruction Inspection By Date __ <br />w <br />r r%RA"1--k1Te 1 rnuniT1nKM- IIJ17Z /ieC i <br />CJ <br />Zt- <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER CE REQ INVOICE <br />� r <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permil�::, Encroachment doc_ vlelluu <br />