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WELL `, RMIT APPLICATION FC`„RVI SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE C <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,Environmentsse so'sDivision. <br /> WELL Location <br /> 675' Oe54 E/fVe#1A SL Cross Street L hrisn+*n Xd City Tragi rip 9530 Parcel# <br /> PROPERTY Owner Dr. 4,1f 6/ogler Address ?.0' Box /oSS City l ra ty. Zlp 95378 Phone#12o-1 1110-1071 <br /> rN s•i - r ..b55*7 j C?)f) 3/3—�8do <br /> C-57 Contractor 6--e 43 'fi`' 'r Address 95d *.x �o�ad City M°�� Z Zip 9ySs3 LicT Phoney <br /> Consultant/Sub Contractor <br /> R /�TC 4SS0Ciok5 T►+t Addresd��7tanc 4, Ove City eJlS�v Lic# Phone#C?by) <br /> GIS Coordinates:X <br /> Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> jj.NEW WELL RIN CPT EOPROBE,HYDROPU NCH,HAND-AUGER,OTHER-) Q DESTRUCTION(chooseOVER-BORE <br /> e beloya) <br /> ISSOIL BORING# Q <br /> Q WELL# Q PRESSURE GROUT <br /> Other: Grout Specifications: I?�uf .elel7tpi3 <br /> COMMENTS: Borin 3 4V /? vhfi� a t�fni�r�y� r�4/ /oi.� it an/e�n�,rr Ti ?^� +�✓i�tr: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 1 1, MULTIPLE CASINGS? Q YES ONO WELL CASING DIA:1V4 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS - Nh TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS Q HOSE <br /> Q AIR SPARGE PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> ❑OTHER: []OTHER APPROX.BORING DEPTH 0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? /UA (if YES,list specifications here): <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O�rd/ina�nccces, Rules and Regulations,.and all applicable California State Laws. <br /> ^,+ -z Sfa-iC� (�co%gisf fi�7� ?ssociq�tS Zrt. <br /> Signed x/(/A �� M-�n+ Title/Company <br /> Print Name AJ4 <br /> -�Ao n rr 97�ma H Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ?G 75 W rt` S�«et <br /> WORK PLAN DATED: 03 ' <br /> .���elr$0� Date Issued o3 09 0 Area_-/ <br /> Application Accepted By /VV 4, Date�— <br /> Grout Inspection 8y Date Final Inspection By <br /> Destruction Inspection By Date - <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: tAID#PE CODES FEE INFOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3v' 5B89 8807 CNcR os At 0 W-3 7 139 <br /> C-57 WC---WAIVER,— C-57 Letter of Authorization to sion permit Encroachment doc 9/27/00 <br />