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VUFI <br /> L <br /> ELL PERMIT APPLICATIO F6YM <br /> IN <br /> SITE <br /> MITIGATION <br /> APR -22 2001 SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1� <br /> ENVIRONMENTAL HEALTH DIVISION`(PH&'LEH'D0) UNIT IV <br /> H <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> o <br /> herr by to S,3. NON-REFUNDABLL PERMIT EXPIRES j YEAR FROM DATE I:!sSUED <br /> .) Cour%�j for a pf.,nni"to Corsa jct andlor instz-q thewwk delcri!)_Jhis appltration Is made in compliance with San <br /> loaQuirt County Development Title.Chapter 9-1115.3 and the Standards Of San Joaquin County Public Health Services,Environmental Health Division. <br /> VELL LocatIQn_,,.,_._ K <br /> Lc�� .Criuss Street A 4-/ cit. <br /> IROPERTY Owne <br /> -k �k jM.Address ;Z5 10,Q Ck"—cit f C <br /> Z <br /> 44 <br /> Li <br /> C91L'0iLPhcnu#_1aJ&3�3cb <br /> ;onsvitant/Sub Contractor <br /> Address_Cary_Lich._Phone# <br /> 31S Coordinates:x Y::::::. <br /> Range —Section <br /> NORK TU!3g PERFORMED, <br /> ,A NEW WELL I BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION(Chc*Sa type below) <br /> B SOIL BORING# 0 OVER­I�ORE <br /> Othen WELL# 0 PRESSURE GROUT <br /> X)MMENTS- <br /> Grout Specifications: <br /> : <br /> rYPr;QF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 110 1 IOLLOW S1 EM DIA_OF BDREHOLE MULTIPLE CASINGS?0 YF-S_URO WELLCAStNGDIA: <br /> ]EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS rYPE`46FCASI�NG. (ISTEEL jjPVC BOTHER- <br /> ]VAPOR H MUD ROTARY DEPTH OF GROUT SEAL -mEmiE'TYPL-TOAC­USED: BAUGERS U HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMIUM FRE-:5-FALL DEPTH IS 30') <br /> .1 SOIL GORING (I HAND AUGER GROUT SPECIFICATIONS: It I <br /> a OTHER:_ 11 OTHM—_ APPROX.GORING DEPTH 112.19 B BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROFOSEI)? I if YES,list specMicarlum"fe).' <br /> 'COMMENTS: <br /> NOTE, OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL TI f LINI FIV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUfRED INSPECTIONS. <br /> I hereby certify Itlat,11 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County 0 C9 Rules !P,2nequlatio and all applicable California State Laws. <br /> /v, <br /> Title/Company �L/ f <br /> Pint W?M <br /> Date <br /> DEPARTMENT USE ONLY- <br /> SITE <br /> NLYSITE MAP IN UNIT IV FILE,ADDRESS' itVA <br /> WORK PLAN DATED' V-XV1 1� <br /> Application Accepted B )g5&-zc Q�, Data 13ove4 0,/ Area <br /> Grout Inspection By jA& Ad&C-6—_ Date.- Final Inspeclion By uLdd6i Date SY 02� <br /> Desinuction Inspecuon Bx Date ii <br /> COMMENTS/CONDITIONS: ii <br /> ACCOUNTING ONLY, AID# Ij <br /> PE CODES FEE INFO AMOUNT UMnIED CHECK# REC'D BY DATE PERMIT I$r-FEVICE REQUEST# INVQIGF <br /> 3 Z_ let q o a z2. <br /> C-57— WC_WAIVER_ C-57 Letter,of Authorization to Sign parm"it Encroachment doc— 9/27/00 <br />