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WELLPET RMIT APPLICATION F6M SITE,,, <br /> � <br /> MITIGATION <br /> L ;= t SAN JOAQUIN COUNTY PUBLIC-HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> E 304 E. Weber, Third Floor, Stockton, CA., 95202 p� <br /> E (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 and the Sta4, dt Sa4n lab l County Public Health Services,Environmental Health Division. <br /> t,, u� _ 1I Assessor's <br /> i WELL Location 1 � fel /Q��(�, ross''JJFjjJ��,,,,���� Ciryj , ( _zjP/Parcel# <br /> I PROPERTY.Owner �� Address ?zf�1 nava d City�I/—TN Zip 9✓8 Phone# g37-M I <br /> q��i # P9l� <br /> C-57 Contractor kle,57t "�� s� <br /> Addreso City dry .�Zip chone# <br /> Consultarst 1 Sub Contractor F�'i' Address //W- CJS( Ity �+ '"'y-) L' � hone# / � O6 <br /> GIS Coordinates:X Y ,Township Range^ Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> EW WELL 1 BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') []OVER-BORE <br /> 0 SOIL BORING# a PRESSURE GROUT <br /> ❑WELL# <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I1 <br /> �.14�ONITORING [-HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS? YES fV0 WELL CASING DIA: 2 <br /> []EXTRACTION 1'a AIR HAMMERIDRIVEN CASING THICKNESS ` —TYPE OF CASING: d STEEL PVC []OTHER: <br /> — <br /> 1] <br /> []MUD ROTARY DEPTH OF GROUT SEAL -fib 25F'�REMIE TYPE TO BE USED: ,AUGERS (]HOSE <br /> []AIR SPARGE 5 1]PUSH POINT GROUT SEAL PUMPED: 0 Yes-41-No (NOTE: MAX] UM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: .�r OLTE/D TRAFFIC BOX or 0STOVE PIPE <br /> r j]OTHER:_0 OTHER APPROX.BORING DEPT <br /> CONDUCTOR CASING PROPOSED? 1�/# (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 /> J I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinJ <br /> County Ordina ces, Rules and Regulations, and all applicable California State Laws. L <br /> ��A�)___Title/Company <br /> Signed x-, L` <br /> Print Name k {rk Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 7 . d s7� <br /> WORK PLAN DATED: 3/ 71hV <br /> y N _ <br /> Application Accepted By � Date Issued Area <br /> I Grout Inspection By Date inal Inspection By Date <br /> Destruction Inspection By **4 Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODE�FE O AMOUNT REMITTED CHECK# REC'D BY DAT PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 WC —WAIVER— C-57 letter of Authoriz tion t si r Encroachment dot 4/27/00 <br />