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���� WELL PERMIT APPLICATION FORM SITE <br />MITIGATION <br />NOV 0 7 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMEN <br />EN -I" 1" NEAL�I i ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />PERMIT/SERVICESAL 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />kpplication 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 />ioaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Olvision. <br />Assessor's <br />NELLLocation 1-603 S• B. ST• Cross Street ejYA9 -,e City 3TbC-157Vt� Zip7Parcel# <br />IROPERTY Owner G.q[ fiZ.4 vs AddressZip 93`�S Phone#z�9 9 y B— �g <br />j <br />:-57 Contractor Address 9So NOe,,e Ay.4,o City Qt&4r, t� iP 3a ic# Phone# yzs 3i3 —3 80� <br />:onsultant / Sub Contractor Address Clty tic# Phone# <br />Range Section <br />;Is Coordinates: X Y , Township <br />NORK TO BE PERFORM <br />NEW WEt.L 1 BORING CPT EOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) a DESTRUCTION (choose type below) <br />M� <br />O <br />SOIL BORING # I] OVER -BORE <br />PRESSURE GROUT <br />V� <br />0 WELL # <br />'Other: Grout Specifications: <br />'OMMENTS: .Z S/DE6.5/06 C P7- <br />p <br />j\ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />' <br />] MONITORING 13 HOLLOW STEM OMvA OF BOREHOLE ;• MULTIPLE CASINGS? 0 YES ANO WELL CASING DIA: <br />] EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING- [] STEEL d PVC 1] OTHER: <br />] VAPOR Q MUD ROTARY DEPTH OF GROUT SEALD ZLH vF&fifZREMIE TYPE TO BE USED: [] AUGERS AHOSE <br />J AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: jtYes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS:"'Z3 %carryy✓�7f <br />3 OTHER: G PT ,[] OTHER C /�T APPROX. BORING DEPTH /Z7 BOLTED TRAFFIC BOX or D STOVE PIPE <br />CON DUCTdR CASING PROPOSED? A" (if YES, list specifications here): <br />'COMMENTS: 1�12,c S 4�+A7-E,t ,eff P 1,49.r <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 , aI have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordin,2 s, Rules and Regulations, and all applicable Californian State Laws. <br />/" Gw� R'^'Ji GEo C o <br />Signed x Title/Company <br />Print Nam _._s� flit/ Q /%�%i >% �� _ _ - - - - Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: t re <br />5 <br />WORK PLAN DATED: I + b <br />Application Accepted By Date Issued I I Area <br />Grout Inspection By Date r Final Inspection ay Date <br />Destruction Inspection By Date <br />COMMENTS f CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REM11T7ED CHECK # REC'D BY DATE PERMIT / SER QUEST # INVOICE <br />C-57— WC= WAIVER— C-57 Letter of Authorization to sign permit Encroachment clot 9/27/00 <br />