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-------------- <br /> {� WELL PERMIT APPLICATION FORM 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 /> I� (209) 468-3449 <br /> pON-REFt3NDABLE PERMIT EXPIRES S YEAR FROM DATE ISSUED- <br /> { ptic�tion[c hereby made t4 San Ja2quln County for a permit to construct andlor install trie work described. This application is made in eampliancg with San <br /> gaquln County Devveelo n�tjent Time. <br /> Chapter 9-1115.3 and.the Standards of San Joaquin County Public Health Services,Environmental t`Division. <br /> HELL Loeatian ✓ ✓ '" Am&/ArossStreeatg; Ib <br /> b7 !'y /Ivor i L/ Address .�d�'/ Ci <br /> OPERTYOwner '��� <br /> y� �Phane# <br /> .'-57 Contractor r!� //��Q �/ �p�j�% <br /> ,�J�- Address i5 /i �' '�'��=� �1 Phone <br /> frisultgrt 1 Sub Contractor �� <br /> X15 <br /> Y ,Township <br /> Coordinates:X Range Section <br /> RK TO BE PaRFORMED: DESTRUCTION.(d)00,38 type below) <br /> ' NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCN,HAND-AUGER.OTHER'S � a OVERSORE <br /> CI SOIL BORING# . D 0 PRESSURE GROUT <br /> '0W ELL# <br /> her: Grout Specifications: <br /> OMMENTS: <br /> T pE OF WELL INSTALLATION D2F- CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA OF BOREHOLE_ MULTIPLE CASINGS?G YES Q NO WELL CASING DIA <br /> ' EXTRACTION a AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING: [�STEEL []PVC OTHER: <br /> l]VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> SPARGE PUSH POINT GROUT SEAL PUMPED: p Yes fl No (NOTE: MAXIM UM FREE-FALL DEPTH IS 30') <br /> (AWL. <br /> L BORING 1]HAND AUGER GROUT SPECIFICATIONS: <br /> ��1,3 OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 1]OTHER- <br /> CONDUCTOR CASING PROPOSED? {if YES,list specifications here), <br /> COMMENTS: <br /> P <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 certify that I have prepared this application and that the Work will be done in accordance with Sari Joaquin <br /> .panty Or Ina es, Rules a egulations, and all applicable Californi tate Laws. _ <br /> �� TtlelCompany <br /> v Date <br /> tl�rirstName DEPARTMENT USE ONLY <br /> IrITE MAP IN UNIT IV FILE,ADDRE S: <br /> ORK PLAN DATED: / o <br /> Date Issued -� r Areae <br /> plications Accepted By Date_ <br /> rout Inspection By Date Final Inspection By <br /> Destructlon inspection By Date <br /> OMMENTS I CONDITIONS: <br /> OUNTING ONLY: AIB# �• <br /> CODES FEE INFO AMOUNT REMITTEE] CHECKS RECD BY DATE PERMIT ISERVICE REQUEST S INVOICE <br /> SR# 00 3 <br /> it Encraachhzent dac 9/27/00 <br /> C-57 WC -WArVER C-57 Letter of Authorization to Sign perm <br />