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— - - ` WELLIERMIT APPLICATION AM SITE <br /> MITIGATION <br /> M4R 1 5 it"A SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRUNMENI HEALTH 304 E. Weber, Third Floor,Stockton,:CA:, 95202 <br /> PERMITISERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 andtheStandards of San Joaquin County Public Health Services,Environmental Health Division. <br /> SilflA LVM(;tir �I Sc$+�• 5+ra% Assessors <br /> WELL Location V,! I�Al2l NsA &14V% Cross Street CaMA/glt 5►.''CCity -ron Zip ?,010 Parcel# <br /> rcift <br /> PROPERTY Ow ,,sjr�Lf.�LV M&sl1 Address '37.< W NAz V4 cityZip''s1Ab�qPhone#LOQ-gY5 <br /> C-57 Contractor <br /> 1Alwr Niv�w+ 0r;11i�AddresW3 Fr*syerAlO aF Cltyto p Azi��YLti sy9 5�nome# 72 7b <br /> A <br /> 837 SHAW RIO. citzi T% ucW-dt7Phone# Zo Y o0 <br /> Consultant/Sub Contractor A • � �. Address # q <br /> GIS Coordinates:X ,Y Township )T_Range �`E-1 Section v <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) [OVER-BORE " <br /> 0 WELL# <br /> 0 SOIL BORING# a-PRESSURE OUT <br /> *Other: Grout Specifications: PorTIA-wiD A+ <br /> COMMENTS AbANOoA WTI) EIS I j'FfEMiE Xj2 will bf VStA Te QtA'oy 0lTIArvD `fs.r7 m;X� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES NO WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS , 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: a OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 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 Californian State Laws. /)A <br /> Signed x Tide/Company /A QaFt7 0/C�S./� • ' •y ' ' <br /> Print Name _r C�F.I/AQ Date / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED`:` }i <br /> Application Accepted By hl p Datelssued � �I ' Area l'�af <br /> Grout Inspection By Date Final Inspection By' <br /> " Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 0 i oSLfF�/ <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />