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'WELL PERM APPLICATION FORM SITE <br /> MITIGATION <br /> NT H r=A L71 H –0 E WV11 11CES <br /> A.?R _501 SAN JOAQUIN COUN Y PUBLIC <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor Stockton, CA., 95202 <br /> (209) 468-3449 <br /> WON-REFUNDABLE PERMn EXPIRES i YEAR FROWDATE ISSUED <br /> lPplirbliars i-.hsmby rr,-.d('to San-losquin Ccunty f!;r zs permit t0 con.sLfur.4andlor install theworY destrib-ad- This appli4;allon Is made in rompilaiicewlth San <br /> loaquin County 0evelopmosm MOP,Clii;ver 9-1115,3 and the Standards of San Joaquin Courity]Publi.c Heallh"Servlces,Environmentat Health Division. <br /> 1 <br /> . � A5se <br /> $or <br /> HELL LocIlan XL � al C�vuISlvet k1 City 7ipg5 p2ParC0ta <br /> aROPERTY Own e fj 14krAddress II 10j <br /> -v <br /> -it zip—phonek <br /> ;-57 Contractor _Address City zip _icp Prlone# <br /> 4 -'on Address City I Lic#._Phone#_ <br /> .suttant f Sub Contractor <br /> !IS Coordinates-,X Y ---------- <br /> TownshIp. !.Range 85cUon <br /> ----- <br /> NORKTOEJ <br /> JE PERFORMEQ; <br /> NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER-) DESTRUCTION(choose type below) <br /> SOIL BORING 9 a OVERBORE <br /> WELL# [I PRESSVRE GROUT <br /> 'other: —GrOUE Spedficallarisil <br /> nMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIPAMNS <br /> j MONITORING ]3 HOLLOW STEM DIAA,OF BOREHOLE_MULTIPLE jCASINGS?[]YES I]NO WELLCASING01k <br /> j EXTRACTION [I AIR HANIMERIDR(VEN CASING THICKNESS TYPE OF CASING: (]STEEL UFvC I)OTHER: <br /> ]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I]AUGERS 1)HOSE <br /> ]AIR SPARGE -jjJPU SH POI N r GROUT SEAL PUMPED: a Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> P <br /> -fl�ZOIL BORING 0 HAND AQGEGROUT SPECIFICATIONS:_ i i I <br /> 0 OTHER- I]OTHER APPROX_BORING DEPTH a BOLTED TsArFic Box vr 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? i (jfyEs,list specificatlians bete); <br /> 'COMMENTS: II <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIF IV INSPECTOR 40 WORKING HOURS IN ADVANCEIFOR ALL REQUIRED INSPECTIONS. <br /> lhereby c tif that 1havepre ared this application and that the work will be done in accordance with San Joaquin <br /> ,.u,,Y , Rule Reg ations, and all applicable California State Laws. <br /> Signed L Title/Company <br /> pdv 14 (fLle- Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' <br /> WORK PLAN FATED: aj <br /> Application Accepted By -iX�C ----Date Issued114 �4 10/ Area <br /> Grout Inspection By_ _.t.Zt _AZIAC211� —Date Ll 1121cl Final Inspection Bly 14Dal <br /> C <br /> Destruction InspecUon By DateC <br /> COMMENTS;CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FE CODES FEE INFO AMOUNT PEMfTTED CHECK# RECD BY DATE <br /> PiRMITISERVICEREQUEW'S INVOICE <br /> 0o55 <br /> Z <br /> C-57— WC_____:_WAIVEA_ C-57 Letter of Authorization to sign per'mit_Encroachment doc— 9/27/00 <br />