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WELL. ."ERIVIIT APPLICATION : RM SITE
<br />MITIGATION
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION (PHS-a-ID)--3)pir,,
<br />304 E. Weber, Third Floor, Stockton, CA.., 95202'1) 5 7
<br />(209) 468-3449 JAN 22 200?
<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 won < described. This apialWitiiii*matiii41dilratilianc.e with San
<br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, E.T.rtfRprnental Health Division.
<br />Assessor's
<br />WF_LL Location r)-10 (A.)?.-t isk Cross Street 6 i'611,1 cay
<br />_ . zip ,_,,O
<br />PROPERTY Owner
<br />C-57 Contractor IV
<br />
<br />b ,A4 44 krk-eco, Address iocI rf Cay Aluttlee Zip `3"--?-'45hone# 9.)
<br />
<br />e1\ Dr, Address c -276.0 (A`rt.Ax C Zip 5 tc uct C-1:7 Phone( ) qi-2- 9 5-52Y
<br />c( 1 C, Address '133-) .-=1/704,tj J1 cltyc.t0-0,, Consultant/ Sub Contractor
<br />GIS Coordinates: X , Y , Township Range Section
<br />
<br />[] DESTRUCTION (choose type below)
<br />[1 OVER-BCRE
<br />Q PRESSURE GROUT
<br />*Other: Grout Specifications:
<br />COMMENTS:
<br />WORK TO BE PERFORMED:
<br />'IKNEW WELL / BORING ( CPT. GECPROBE, HYDRCPUNCH, HAND-AUGER. OTHER')
<br />a SOIL BORING #
<br />.,a\WELL #
<br />TYPE OF WELL INSTALLATION TYPE
<br />,KVIGNITORING *CLLOW STEM
<br />E(TRACTION 3 AIR HAMMER/DRIVEN
<br />a VAPOR El MUD ROTARY
<br />- AIR SPARGE a PUSH POINT
<br />U SOIL BORING fl HAND AUGER
<br />B OTHER: 11 OTHER
<br />'COMMENTS:
<br />CONSTRUCTION SPECIFICATIONS
<br />DIA. CF BOREHOLE :2,51 MULTIPLE CASINGS? fl YES ..4.010 WELL CASING
<br />CASING THICKNESS C__CL 6 TYPE OF CASING: j] STEEL VC U OTHER:
<br />DEPTH OF GROUT SEAL 7-(-e-.1" TRE_MIE TYPE TO BE USED: UGERS U HOSE
<br />GROUT SEAL PUMPED: a Yes 1/(kNo (NOTE: MAXIMUM FREE-FALL DEPTH IS :30')
<br />GROUT SPECIFICATIONS: e;?'-f /4 e.:-.4•A. ilodeG,,,,,,Js' .4- 6-410;.) /-
<br />APPROX. BORING DEPTH -7-'; gc8CLTED TRAFFIC BOX or 0 STOVE FIFE
<br />CONDUCTOR CASING PROPOSED?Ai/ ) ( if YES, list spefications here):
<br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS.
<br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.
<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 x 64,/i...0 - ./L— Title/Company S +,,c--? 6 .'/' c,/
<br />1 .
<br />Print Name P.I1 --7‘ V' k il lifV10/,, ' Date I 1 J -7,/iG,-'1--
<br />DEPARTMENT USE ONLY
<br />[,', (A- ei.7,4.; (..-e • (if /ic.,-4-1- P ( ci.
<br />70C)
<br />
<br />) Date Issued ) 2- 2- ) 0 2_ Area
<br />Final Inspection B (A.r if Ai
<br />
<br />Application Accepted By
<br />Grout Inspection By
<br />Destruction Inspection By
<br />
<br />Date
<br />Date
<br />
<br />COMMENTS / CONDMONS:
<br />
<br />ACCOUNTING ONLY: AID# Far# _
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ..1- / SERVICE REQ INVOICE
<br />I
<br />- , - a pyynn
<br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_. rtc-r-qa
<br />
<br />SITE MAP IN UNIT IV FILE, ADDRESS:
<br />WORK PLAN DATED: Aup,
<br />IL-
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