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ZI <br /> WELNEIT APPLICATION11FORW <br /> W. <br /> SITE <br /> J PtMITIGATION <br /> PPR SAN jDAQUIN COUNITY PUBLICHEAL.71 H.10ERViCES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-Rf-r-UNDABLE PERMIT EXPIRES I YEAR FROM IDATE ISSUED <br /> kpplic4on is hemby rade to San.1zaquin County far zi panril to construct amlor install the Work desc6bed. Ttzis.application Is made in compliance with San <br /> loaq uin County Development Title,Chapter 9-1115.3 and.the Standards of San jo2quln County PuWr'H ealth Services,Environmental Health Division" <br /> i Azsestoft <br /> WELL Locatlon_ Crass Street city Zip Parcat# <br /> 'RQPZRTY Owner- &AW e,� <br /> ,�Contractor CAddress. SVT city 1" <br /> phono#_ <br /> 'onsultard I Sub C4nrracior—,::�-4 Address <br /> !IS Coordinates:X az 'Y 'Township. Range Section <br /> NORK TPq LP__FORM E 0- <br /> _ I-I( <br /> NEW WELL!BORING(CPT.GEOPROBE.HYOROPUNCH,HAND AUGER.OTHER-) 0 DESTRUCTION(ohoo$a type below) <br /> ;"OIL BORING# 11 OVER-BORE <br /> a WELL# it [I PRESSURE GROUT <br /> 'Other. Grout Spedfications: <br /> �OMMENTS: Ii <br /> rYPg OF MIELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> j MONITORING 0 HOLLOW STEM DIA.OF i3ORZHOL5._MULTIPLE CASINGS?EYES I]NO WELL CASING DIA; <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OFCASING )7 STEEL 13PVC 12OTHER: <br /> ]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIETIYPETOBGUSED: I]AUGERS [I HOSE <br /> ]AIR SPARGE _A31USH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,4SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: !I <br /> a OTHER: I]OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX.or EJSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? it (if YES,list specificatigna hare)' <br /> 'COMMENTS-, <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 /> if <br /> I hereby ceji at have prepd this application and that the work will be'done in accordance with San Joaquin <br /> diva <br /> County <br /> Rules 3pd gulAt <br /> We .-ions, and all applicable California State Laws. <br /> Signed X--�= I e c 721-1,t c Zs­l/ <br /> Print e _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' TILE COPY <br /> WORK PLAN DATED: fiE <br /> Application Accepted By Date tssued—!� u folArea <br /> Grout Inspection By---j14zN�jVr <br /> -Date Final Inspection By Date .. /PY— <br /> Destruction Inspection By Date i7` <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> FA('A <br /> IFE CODES IFEE INFO I AMOUNT REMTYTEE) CHECK# T RECBY DATE PERMIT/SERVICE REQUEST ay INVOICE <br /> t4- I SR# 3 <br /> c-57-- WC---WAIVER -57 Letter of AuthoriZation to Sign permit, Encroachment doc�— <br /> C 9/27/00 <br />