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WELL rERMIT APPLICATION FOkoM 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) 46&3449 <br /> NON -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Npplication 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 <br /> Health DivisYon . <br /> , / Odr4 F( . *. + Cross Street ✓ 4 ^ F"IF1 City gv-f cKa A Zip %SOBS Parcel# - � <br /> NELL Location 4(/04/ <br /> C� JV* l C�tc f B,pAddress /0 / 3 U r Biu t Cary S14 zip9SOYPhane# qi� yyy72a � <br /> PROPERTY Owner 7 C-57 Contractor <br /> U6 W � 6r: / / : Aj Address FPO got( g //v CItyS%r1d4*^ Zip <br /> C-57 <br /> �o. 737r/ 28/r <br /> Consultant / Sub Contractor W G t(Act — ' I Address 30so - ^ /�J-1r1r ( City r`� pLic# 7o729 �Phone# �/e 374 / Lav <br /> GIS Coordinates: X , Y , Township T ` Range " E Section <br /> WORK TO BE PERFORMED: <br /> <NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') /J p DESTRUCTION (choose type below) <br /> C� S <br /> H SOIL BORING # p {�,� Yn`1v!L g OVER-BORE <br /> U WELL # A S C— �/ aJ p PRESSURE GROUT <br /> r GROUT SPECIFICATION <br /> "Other: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORINGIOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS? BYES �O WELL CASING DIA: Z <br /> U EXTRACTION a AIR HAMMER/DR <br /> CASING THICKNESS Sc� y' ° TYPE OF CASING: F STE VC a OTHER: <br /> Cl VAPOR F MUD ROTARY DEPTH OF GROUT SEAL — 2 O TREMIE TYPE TO BE USED: H AUGERS ROSE <br /> AIR SPARGE (l PUSH POINT GROUT SEAL PUMPED: xYes D No (NOTE : MAXIMUM FREE-FALL DEPTH IS 301) <br /> [] SOIL BORING 0 HAND AUGER GROUT SPECIFICATION Ne"r' CA"" <br /> Q OTHER: H OTHER APPROX. BORING DEPTH 30 'Fli'f VOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDy ( if YES , list specifications here): <br /> COMMENTS: <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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 , State Laws, and Rules and Regulations of the San Joaquin County, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> / <br /> �- Title/Company Sr t ^ ✓' � ° nn+r�-fes/ �PCe. . jf7r- wa /1A4 _ SVG/ <br /> Signed x <br /> Print Name �a ���w ni Date .7 <br /> SITE MAP IN UNIT IV FI ADDRESS /WORK PLAN DATED <br /> EP T USE ONLY <br /> Application Accepted By _ Date Issued •t% a \ <br /> Grout Inspection By <br /> Date al Inspe on By Date J U <br /> Destruction Inspection By Date <br /> COM ENS_ � CnONDI ONS: 20 O <br /> i1 YM/� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY PERMIT / SERVICE REQUEST # INVOICE <br /> Ov 21 2 Zoo <br /> C-57 WC/WAIVER. C- 57 Letter of Authorization to s ' n e Encroachment doc_ 7/ 17/00 <br />