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WELL PERMIT APPLICATION F ., RM SITE <br /> MITIGATION <br /> JAN 2 2002 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 L . <br /> i l <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 41115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> n � 1 Assessors <br /> WELLLocaticm � oJ fzl - aaI"��+'1't�. Cross Street �+ r�G `� City +Ob&l=zip 9 o Parcel# <br /> PROPERTY Owner E (-urpr ) li�r"}'�PS Address 1'U � (7�� 9 /71Q� � Ciry �T�p��>�-Phone# �/ s<. - 901U <br /> C-57 Contractor f-i- �Y�/n'� / Address i�3� 5 �;;w✓ 1�bfci nn _Zp �I /�J Lic# GJ - Phone# c�y( 7 '/�I)G . <br /> consultant ] Sub Contractor /- & r Address R3� S�wr. � Gf CIty- - ,Z:�ilv,Lic# J2:1. Phone# 70 ' /U <br /> GIs Coordinates: X , Y , Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') a DESTRUCTION (choose type below) <br /> 7j!I�SOIL BORING # O OVER-BORE <br /> OT <br /> I O WELL # p PRESSURE GROUT <br /> *Other: tf v7 n - Graut Specifications- - <br /> COMMENTS: / <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING O HOLLOW STEM DIA- OF BOREHOLE__ MULTIPLE CASINGS? OYES ONO WELL CASING D <br /> O EXTRACTION O AIR HAMMERORIVEN CASING THICKNESSL TYPE OF CASING: O STEEL 11 PVC O OTHER: <br /> O <br /> o VAPOR MUD ROTARY DEPTH OF GROUT SEAL IL+. TREMIE TYPE TO BE USED. O AUGERS O HOSE <br /> OAIRSPARGE ir(LISHPOINT GROUT SEAL PUMPED: 11 Yes Mo (NOTE: MAXIMUM FREE-FALL DEPTH JIS30') <br /> " OIL BORING 1] HAND AUGER GROUT SPECIFICATIONS: I yii6J 5(d & S�fHL1SZf r- O Pfi//'"f <br /> 0 OTHER- O OTHER APPROX. BORING DEPTH O BOLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?—.may/ .-lLl ( if YES, list specfintions 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 /> that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> 1 hereby certify p P P <br /> s and a ulations and all applicable California State Laws, <br /> County Ordinances, Rule pP _ <br /> Signed x Title/Company o `f <br /> C) <br /> Print Name f I /i, Y1 ) �✓__✓-t G ✓I Date I �' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED ' aY DC � 2Y � �01 <br /> Application Accepted By Date Issued 0/�J" c�Q 2 Area <br /> Grout Inspection By - Date / V/ 6 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDRIONS: 61152" <br /> ACCOUNTINGONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST INVOICE <br /> �so �� �9 X60 v / 2 � <br /> doc_ 9/27/00 <br /> C-57_ WCWAIVER_ C-57 Letter of Authorization to sign permits Encroachment <br /> = <br />