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WELLIT APPLICATIOM FO SITE <br /> ' <br /> W � v ED MITIGATION <br /> n .. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - . <br /> FEB 0 1 2002ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> J UNIT IV <br /> ENVIRONMENT HEA4 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j <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 /> �� <br /> Assessor's -� <br /> WELL Location ZILI`f FOn-to.v�q &J� cross Street U f �.V.. City 5-COc4tOA Zip 457A6 Parcel# <br /> PROPERTYOwner l .t-t cr� Stoc-V.7YO✓t Address ZJ`00 NO„Vy City 5t0C,&tON Zipq5-ZC*Phone# <br /> C-57 Contractor tk' noc \—.' o rc\. . Address CityZip Lic# Phone# ' <br /> Consultant/Sub Contractor ATC_i-CSSijC+ZYIC. Address City Lic# Phone# <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type beloly) <br /> o SOIL BORING# 1]OVER-BORE <br /> ,`WELL# rA ts-)-7 . ., O PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> tl 1 <br /> • MONITORING )<;OLLOW STEM DIA.OF BOREHOLE 2," MULTIPLE CASINGS?0 YES )kF10 WELL CASING DIA: <br /> H EXTRACTION [I AIR HAMMERIDRIVEN CASING THICKNESS %jA L(0 TYPE OF CASING: a STEEL 'PVC t]OTHER: <br /> 6 VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL R I TREMIE TYPE TO BE USED: ,AUGERS p HOSE <br /> p AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: O Yes .h�No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: G ro o-{ <br /> o OTHER:_O OTHER APPROX.BORING DEPTH "3O I OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? tj C) (if YES,list specifications here): <br /> *COMMENTS: <br /> i <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> I <br /> Signed x ll wTn'n J�8-o YT(�,tll/ - TiUe/Company L7('0. t'C I �- KS S�L10.`�LS <br /> Print Name <br /> t1 P,U-W VEL- ��O yVlyt_.I Date 1 l l02 <br /> DEPARTMENT USE ONLY i <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: k <br /> Application Accepted ey Date Issued O I Area ` <br /> Grout Inspection By Date ` inal Inspection By Date <br /> Destruction Inspection By j Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# pArt <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE BY DATE PERMIT!SERVICE REQUEST# INVOICE. <br /> 3 t90 5U All 0 ZIA4'L SR# Z i <br /> C-57_ WC=WAIVER_ C-57 Letter of Auth iia i' a sign permit_ Encroachment doc_ 9/27/00 <br /> I <br /> • <br />