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• r ' r FILE COPY <br /> -- r,,l WELL PERMIT APPLICATION FORM SITE <br /> r MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 `3 ZU01 UNIT IV <br /> MAR ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ��1VIRONME.,F''-F,LIH304 E. Weber, Third <br /> Floor, <br /> Stockton, <br /> octon, CA., 95202 <br /> pERMITISER•IICES <br /> 449 <br /> NON EFUNOABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> %pplication Is hereby made to San Joaquin County r a permit to construU and/or install the work described. This application is made in compliance with San <br /> Joe uin County Dev�el pment Title,Chapter 9-111 .3 and the Standards of San Joaquin runty Public Health Services,Environmental Health <br /> Division. <br /> J� y ovy{ Ci $koc6t Zip 0c52obParcel# <br /> NELL uaa�lon�ZyS W • w tr \N!q Cross Street °t h <br /> PROPERTY Owner fr 4..a W tzrD Addresssg LOl S • qk'` S� city'IYIOaI.si'D ZIP 5—0 Phone# 1' <br /> C57 Contractor i W Oci,+\\'�.y r+aare5s i 0 "�X LW. City'Wck%�, zip`S b,Lill uc# o�Phone# $g- g�3— Z q S <br /> 2iLUcf��Lic# Phone#;� <br /> Consultant I Sub Contractor c <br /> GIS Coordinates:X ,Y <br /> Township.Range Section <br /> WORK TO BE PERFORMED: -) DESTRUCTION(choose type below) <br /> II NEN!WELL/BORING(CPT.GEOPROBE,H ROPUNCI HAND-AUGER,OTHER') U OVER-BORE <br /> SOIL BORING S$10 p PRESSURE GROUT <br /> WELL# 'M`n1 l� O Grout Specifications:_ <br /> "Other: <br /> COMMENTS: W-0 •' P °"`^ — a r^(, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 4MONITORINGV t HOLLOW STEM DIA.OF BOREHOLE_9 " MULTIPLE CASINGS?DYES 0 NOS,V LL CASING DIA:_ <br /> EXTRACTION Q AIR HAMMERIDRI EN CASING THICKNESS 2-" TYPE OF CASING: a STEEL bPVC. OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL 0' — (o t TREMIE TYPE TO BE USED: J AUGERS p HOSE <br /> 0 AIR SPARGE , n PUSH POINT GROUT SEAL PUMPED: p Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> It SOIL BORING 1V a HAND AUGER GROUTSPECIFICATIONS: v+a� BOLTED TRAFFIC BOX or []STOVE PIPE <br /> OTHER: II OTHER APPROX.BORING DEPTH <br /> CONDUCTOR CASING PROPOSED? �i O(It YES,list specirns here): <br /> Q-¢� c�.� <br /> `COMMENTS: <br /> NOTE: OFFSITE B RINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPEC OR 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 Ordinances,Rules a d eg I t1 ns, and all applicable California State Laws. <br /> .�� Title/Company 6--a o `C� <br /> Signed x 3 I I �( l �) <br /> Date <br /> PrintName a. }`� ` DEPAARTMENI USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE S: /L E /� ' e <br /> WORK PLAN DATED: <br /> NodipDate.Final <br /> b '000 (N /, <br /> Date Issued �O/ Area <br /> Application Accepted By Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By <br /> Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID#, <br /> PE CODES FEE INFO AMOUNT RE ED CHECK# RE 'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> t 9/27/00 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment do <br /> ..., �.... , ]nn-1a HI 4T EEVE89VGOZ 9S:ET L00Z/8Z/Z0 <br />