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WELL'PERMIT APPLICATION_ FO 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 7 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,Environmental Health Division. <br /> I <br /> Assessor' r <br /> WELL Location Cross Street - City S7-CGKI_ON Zip ZD Parcel#� <br /> PROPERTY Owner &LAmnC-1?1C*P16-..b Address PO Bax 567), _City-8 A�par�jC ZipgO(oZ2 Phone#A25q`J-m! <br /> C-57 Contractor W_ µA7-MAT L"ZtIituddress3ZV3 PtTzgpe-9 YLD Ej- _Cityter' Zip ]q Lic#55+'P17Phone# 61§13&-w <br /> Consultantl Sub Contractor SEQP-Tr,4exuxnon.%41_- Address 2LOC) GLfc4ZEgj City° t-ic# XIA Phone# � <br /> -04 <br /> GIS Coordinates:X Y Township Range Section <br /> " <br /> WORK TO BE PERFORMED: <br /> []NEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> J SOIL BORING#591 . S8.44 sb-&- 1]PRESSURE GROUT <br /> n WELL# d <br /> *Other: Sct4 ozj,� , �. o' Mott r Grout Specifications: �1'tw+1 E l'tPE I <br /> COMMENTS: f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS }I <br /> p MONITORING I HOLLOW STEM DIA.OF BOREHOLE $+ - MULTIPLE CASINGS?n YES n NO WELL CASING DIA: NA ? <br /> n EXTRACTION []AIR HAMMER/.DRIVEN CASING THICKNESS_ N A TYPE OF CASING: [I STEEL (]PVC n OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL Z01 TREMIE TYPE TO BE USED. n AUGERS p HOSE <br /> n AIR SPARGE []PUSH POINT GROUT SEAL PUMPED: n Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: Tr&K%E Pt4E 1FR:6M warorn -m 1-00 _ <br /> n OTHER: []OTHER APPROX.BORING DEPTH ZO 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?� NO (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 /> hereby ceify that I h ve prepared this application and that the work will be done in accordance with San Joaquin <br /> County O i anc , u es and Regulations, and all applicable California State Laws. <br /> Signed x TitlelGompany SFG02 �.n tOn <br /> Print Name 1n Date f 2 O <br /> DEPARTMENT.USE ONLY <br /> r 3 <br /> SITE MAP IN UNIT IV FILE, ADDRESS' / <br /> WORK PLAN DATED: / <br /> Application Accepted By Date Issued / _Area <br /> Grout Inspection By Date d� Final Inspection By Date " <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE - PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 WC---WAIVER,---- C-57 Letter of Authorization to Sign permit_Encroachment doc 9/27/00 <br /> it 4 <br />