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WELPERMIT APPLICATION RM 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 FIL <br /> "CU <br /> w (209) 468-3449 <br /> NON-Rt=FUNDABLE PERMIT EXPIR>rS i YEAR FROM RATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This applicatirnti is made in compliance with San <br /> Joaquin County Deevel ment T-iLte.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Service(s�Environme AsDivision- <br /> Joaquin <br /> Cross StreetAA City Ziif TJda- <br /> ((VELE Location (,{/}� <br /> PROPERTY Owne 4 <br /> ddress I CiPhonesfl <br /> j• <br /> 60 <br /> C-57 Contracto Address K l� Ci z+p 3 V &A-DaPhon <br /> Phone#gl//]]l <br /> Addre <br /> s # C 7flrZ1 <br /> Consultant/Sub Contractor + <br /> GIS Coordinates:X ,Y,.Township Range Section <br /> WORK TO BE PERFOR DESTRUCTION(choose a below <br /> EW WELL!BOR <br /> (CP EOPROBE,HYDROPUNCH HAND-AUGER.OTHER") Q . <br /> SOIL BORING# • YL OVER-BORE <br /> Q WELL# Q PRESSURE GROUT <br /> 'Other Grout Specifications: <br /> comM TS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 1]HOLLOW STEM DIA-OF BOREHOLE MULTIPLE CASINGS?[]YES a NO WELL CASING OIA: <br /> U EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL p PVC BOTHER; <br /> 13 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS p HOSE <br /> ()AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED:� [I Yes [)No (NOTE: MAXIMUM FREE:-FALL DEPTH IS 30') <br /> 1�1004L BORING `[ HAND AUGER GROUT SPECIFICATIONS: /� <br /> {]OTHER: �'t�THEIR APPROX.BORING DEPTH L/ []BOLTED TRAFFIC BOX or B STOVE PIPs= <br /> CONDUCTOR CASING PROPOSED? (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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or es, Rules a ulations, and all applicable California State Laws. s <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> I <br /> SITE MAP IN UNIT IV FILE, ADDRES <br /> WORK PLAN DATED: <br /> Appk:ation Accepted Ely Date Issued ��� Area ' <br /> Grout Inspection By Date "�YR-al Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMO NT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> £ta 9tld <br /> 80013 HIA13 EE7E69b60Z TE=ET 000Z/60/Zi <br />