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Date Isavecl f'-( fat <br />Final Inspection By (L-,. AA t Ark Date Sr- 0 <br />C-57 WC 9/27/00 Encroachment doc -WAIVER C-57 Letter of Authorization to sign permit <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />ACCOUNTING ONLY: AID# <br />-- <br />FAc.ft <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # RECD BY DATE PERMIT/ SERVICE REQUEST 0 INVOICE <br />32 CG i C6I <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS CONDITIONS. <br />Date 5-1 I fe,/ <br />Date <br />Area <br />(4-AAAA ,, <br />ji / <br /> <br />WELL PERMIT APPLICATION FORM <br /> <br />' <br />i I <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />APR - 2 2001 SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />AMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />1V/SERVICES (209) 468-3449 <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />‘pplication is hereby mode to Son Joaquin County for a of1rmit TO construct andlor install the work described. This application Is made in compliance with San <br />loaouin County Development Title, Chanter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />'YELL Location /cP- 7,'4_, k8).- CW3;3 Sheet (Av.. City _51:7-c-i27, Zip 9`72-01,0 Parma- 777-v1i <br />NiOPERTY Owner Address 779''' g;PC' 6'8 City Zip Phonett • <br />-57 Contractor / mciress9 Of3o)c 3, — City RIcAYSfEt ZipCN57/ Lic#310°3-7 Phone* ?-07 3 4A-i Y3P ei) ..i* ',/,-(c/V <br />Address 1 I .3 CO Meitn I+ fOvit 0,City R e Lic# Phone# 91(0 `65-3 st)2_, :onsultant f Sub Contractor <br />3IS Coordinates: X .Y ,TownshIp Range Section <br />WORK TO TIE PERFORMERL <br />'SZCIEVV WELL / BORING (CPT. GEOPROBE. HYDROPUNCH, HAND-AUGER. OTHER') t) DESTRUCTION (ChOosa type below) <br />I] SOIL BORING # 19 OVER-BORE <br />0 WELL /f 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />rYPE QF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ONITORING 041OLLOW $T EM DIA. OF BOREHOLE 2. MULTIPLE CASINGS? DYES D NO WELL CASING DIA. 9"-- <br />] EXTRACTION [) AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC D OTHER: <br />3 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO SE-USED: U AUGERS U HOSE <br />] AIR SPARGE CI PUSH POINT GROUT SEAL PUMPED: (3 'Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />] SOIL BORING TI HAND AUGER GROUT SPECIFICATIONS: <br />U OTHER: U OTHER APPROX. BORING DEPTH //I-0 tl BOLTED TRAFFIC BOX or 13 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNI I- IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin <br />County s, Rules Regulapons, and all applicable California State Laws. <br />Signed Title/Company /.//C r 14.k ei/Ge.- • 77t- 7 ( <br />Pri Date <br />DEPARTMENT USE ONLY <br />OMME NTS: