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Oct-08-01 12 : 36P P.02 <br /> 10 :0 , P'-W- U4 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Webdr, Third Floor, Stockton, CA, 95202 <br /> (209) 468-3449 <br /> APDkffwn is hereby rade b San log �� O FUNDA13t$PERMfT EXppZES 1 Y1=AR FR< pgTE ISSUED <br /> Joaquin County Deve Q� CourRy fix a permit b oonattuct and/or kutatl the w�Ork desrnbed_ This <br /> bprnent rile.Chapier 9-t i 16.3 and the Standards of San Joa �'�� made In eortmpDIvise n. San <br /> /_ � Quin County Public Health SeMoes,Environmental Heaph Division. <br /> WELL Location S�� oN S i Cross Street / one city H_oK CA ZI ssemes <br /> P <br /> PROPERTY Owner L'i Address <br /> '--_�2jp Phoned <br /> C,117 Caxrictor 6 re 1 S Address City 9'HSS 3 <br /> uck Phone# ZS 3t <br /> t:onsultsrd/Sub Contraacr�C )m2aty-9.1kvd UC# Phone# 5f1, z5►-Zy2/- <br /> GIs CoCord�ir�les: 63� a .Y �/ 5 ,N so�,shlp_��uQ 3 _Rsape <br /> E PE FO MED: <br /> VNEW WEU./BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,UTHER") Q DESTRUCTION(010M <br /> 8SOBORINGM CPT/wS Na�oZ ( iol�rirs� Q�R�Etype below) <br /> " �►% 13 PRESSURE GROUT <br /> COMMENTS: bar 50' GrautSpeoflcatiau: <br /> TYPE OF WEL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONlrORING p HOLLOW STEM DW OF BORER tI <br /> �EXTRACTION a _Mt1LTtI'LE CASINGS?(]YES �(No WELL CASING DIA.- <br /> Q AIR HAMMERIDRIVEN CASING THICtWESS--&L& _TYPE OF CASING: Q STEEL E PVC VOTHEf;&_ <br /> 11 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL baler bo�in TREMIE TYPE TO BE USED: <br /> 11 AIR SPARGE PUSH POINT GROUT SEAL_PUMPED: Yes �'�� 1�NOSE <br /> R Q No {NOTE; MAXIMUM FREE-FALL DEPTH IS 30) <br /> 11 SO4 WRING )(HAND AUGER GROUT SPECIFICATIONS: 2!5/e ya j%bi-b VI <br /> 0 OTHER: M OTHER C-fl APPROX.BORING DF_PTH fD-rio � w a BOLTED TRAFFIC BOX or p STOVE PIPE <br /> 'COMId>~NTS: <br /> CONDUCTOR CASING PROPOSED? jN1D (ifYES,Ust"clf=tions hero): <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 /> I hereby Certify that i have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord'n ces, s and Regulations,and all applicable Callforrlla State Laws. <br /> l l y' any d r eo 1 sf 2m HILL <br /> Print Name DIYl O QS Date 10 0� O : <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED. <br /> Application Aooepted ey r. a ?p p <br /> Gate Issued 1 ,tea <br /> Grab Inspection By Dat¢ ,- <br /> Flnal bispeCtion By Data <br /> DastruCtion Inspection BY Date J <br /> COMMENTS/CONDn'10NS: <br /> ACCOUlfrING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMfTTED CHECK V l C'D tiY �11 PSRMrI!SERVICE REQUEST fNVOICEO 0 <br /> C-57— WC -WAIVER__ C-57 Letter of AuthoA zqt no,,sigrf pay tnjt Encroachment doe_ 9/27/40 <br />