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04/ 04/ 2001 130:34 .204683433 IF FLOUR FACIE. 01 <br />1,t4-1 - 7 <br />WELL PERMIT APPI IrATInN FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERViCES <br />ENVIRONMENTAL HEALTH DIVISION (1S-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />%MI gI— <br />MITIGATION <br />UNIT IV <br /> <br />NON•REFIJNDABLE PERMIT EXPIRES YEAR elzum DA1t iSSUED <br />,pplicatian is 'nereby metiE i.o San ..}(Ji2QUICI C,Pvfity iPf pamit to corc;t4r.,1 ar,ditr ;n3Vail tht =Kt:est.:fit/ad. This applirarj.on i made in compliance with San <br />oaquin Cnkinty Development litIn Chapter 9-1115.3 and the Standards of San JoaQuin County Public Health Services, Environmental Health Division. <br />Assessor's <br />j2_o 7 Cross Street en.L../ City ....774-C7c.. Pareel# YELL Location <br />Address /1.3...)'477 frfeivi ei , city Lic#'1‹,.C-6.3phon&p. - j- <br /> <br />Rene Sec ti <br />YORK TO BE PERFORMED: <br />j NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH. HAND-AUGER, OTHER') <br />u SOIL 130RiNG # <br />DWELL # <br /> <br />A.DESTRUC;TJON 'choose type below) <br />Ii PRESSURE GROUT <br />OVER-BORE <br />Other: Grout Specifications: <br />30MMENTS: <br />rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />] MONITORING U HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? 0 YES LI NO WELL CASING DIA: <br />] EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING. fl STEEL rj PVC 11 OTHER: <br />] VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREM1E TYPE TO HE USED: fl AUGERS ij HOSE <br />] AIR SPARGE U PUSH POINT <br />] SOIL BORING 0 HAND AUGER <br /> GROUT SEAL PUMPED: Ei Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH fl BOLTED TRAFFIC SOX or fi STOVE PIPE ]OTHER: 0 OTHER <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />6 trti,s- Address 'ROPERTY 0 Wntar -;-1 <br />.57 Contractor <br />:onsultant / Sub Contractor ‘;t/ <br />;IS Coordinates: X <br /> <br />city_7c-Tcrfr7Z-3Ni Zip _Phone# <br />eh:VA Address 3.3 City Lic# Phone# <br /> , Township <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared thitaPplication and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules-43nd RguIations, and all applicable California State Laws. <br />/ <br /> <br />x Tide/Company ,/ /7-1-P <br /> <br />Print Na e')/ (24' •Z,k.,,av , <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />7ec .1 <br />,1 <br />Application Accepted By <br /> <br />Date Issued Area <br />Date s.(/3c/c( Date 5- <br />Date <br /> <br />Grout Inspection By <br /> <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK $ REC'D BY DATE . _ - • VEST $ INVOICE <br />3 5—c72._ c) . o 0 003-66,6 141 ki 1 2.71 'put 00 21/4 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sig pe mit ment doc /