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WELL i°ERMIT APPLICATION F._.ZM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> OCT;0 <br /> 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> FILE COPY <br /> (209) 468-3449 <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 work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> l 1 . Assessor's <br /> WELL Location �O l C- nn ni^^t K''.d �lJCLU Cross Street City� Zip �Parcel# <br /> PROPERTY Owner l_ V� A Address n.SL City Zip Phone# <br /> C-57 Contractor Address City='�z Zip Lic# Phone#9LS-3�Z-'5 E� <br /> Consultant/Sub Contractor v�'7� ress TZ� S�"AA 1 V(,� City 1 Lic# Phone# -I oL <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED- <br /> 0 NEW WELL/BORING( P ,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> &SOIL BORING# 'L7T _ 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ?_ " MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: /UA, <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ( TD ' TREMIE TYPE TO BE USED: [AUGERS 0 HOSE <br /> 0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: -eYes{� 0 No (NOTE:: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: y"1 1 \o AAAo ± <br /> OTHER: C,�'T 0 OTHER APPROX.BORING DEPTH ���r 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specificatio s here): <br /> 'COMMENTS: -sa l <br /> L ; <br /> NOTE: OFFSIi-TE'lJ6RINGS 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 Or i an es, Rules and Regulations, and all applicable California State Laws. (n 1 <br /> Signed x Title/Company i>1 U f /1d� <br /> Print Name ��� 1�� lie- Date 1�!n <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ;1o1 <br /> WORK PLAN DATED: ��, -6 to <br /> • Date Issued &A"?/,0 Area <br /> Application Accepted By C <br /> Grout Inspection By J4/y-\ u{ !�C Date Final Inspection By Date <br /> Destruction Inspection By 6 Date <br /> COMMENTS/CONDITIONS��S >0/6��r/"e," <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> moo/ �� �{� /��G �z7o r 2-2901 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />