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WELL icR <br /> MIT APPLICATION FG SITE <br /> SAN JOAQUiN COUNTY PUBLIC EALTH SERVICES MITIGATION <br /> IV <br /> 01 ENVIRONMENTAL HEALTH DAIISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Sta kaon, CA., 95202 <br /> E �1ROj`MElyj NEAP TSI (209) 468-34-49 <br /> PERM�TISuRVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instalE he work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmenttaal Health Division. <br /> 3 Cross Street City_�A _Zipg� Parcel# <br /> WELL Location <br /> PROPERTY Owne Address Glty lap Phone# <br /> � �;r,��- <br /> C-57 Contractor <br /> � Address <br /> Consultant I Sub Contractor <br /> 1n cess 3� S Clty I;c#��Phone# 0 <br /> GIS Coordinates:X <br /> ,Y Township Range Section <br /> WORK TO BE PI,RFORME DESTRUCTION(choose type below) <br /> jl NEW WELL.I BORING W.GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 1]OVER-SORE <br /> &SOIL BORING# 1]PRESSURE GROUT <br />. �WELL# " <br /> 'Other. Grout Specifications' <br /> COMMENTS: <br /> TYPir OF WELL INSTALLATION TYPE CONSTRUCnON SPECIFICA IONS <br /> 1]MONITORING (I HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?l]YES a NO WELL CASING DIAL ►�} <br /> LL - <br /> EXTRACTION [I AIR HAMMERIDRIVEN CASING•THICKNESS_-1—jr TYPE OF CASING: [)STEEL (I PVC [[OTHER: <br /> VAPOR [I MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: ,AUGERS o HOSE <br /> []AIR SPARGEPUSH POINT GROUT SEAL.PUMPED: ;K'Y s 1]No NOTE: MAXIMUM FREE-FALL DEPTH_IS 30') <br /> q SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: <br /> ` BOLTED TRAFFIC BOX or [)STOVE PIPE <br /> �f]THER: (� ❑OTHER_ APPROX.BORING DE;PTN F <br /> D <br /> QQ CONDUCTOR CASING PR $ a? _ ^(if YES,fist specifications here): 1 <br /> "COMMENTS: Vftc h.Lt <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE S 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 dome in accordance with San Joaquin <br /> County Ordin ce R es and Regulations,and all applicable California State Laws. - <br /> Signed x <br /> Title/Co pony t' <br /> Print Name L\ Date <br /> DEPARTMENT U E ONLY t <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK'PLAN DATED: <br /> $tAreabop -D <br /> Application Accepted By Date Issued ZS O <br /> By <br /> Date Final Inspection By <br /> Grout Inspection Date_ <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMTMD CHECK# REC'D B TET/SERVICE REQUEST# INVOICE <br /> G-57 W( -WAVER C-57 Letter of Authorization c sign permit Encroachment doc 4/27/00 <br />