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WELL k-fiZi RMIT APPLICATION FG­N! SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> OCT 3 2 2441 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> Vik�OM�Ps 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> UJ �RMI�TjSER1�'I��� <br /> {209) 468- <br /> P9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1YEAR FRONT 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 matte in compliance with San <br /> Joaquin County Development Title,Chapter 11-1115.3 and-the Standards of San Joaquin County[[Public Health Services,Environmental Health Division. <br /> AssessWELL Locatlon tai�) �- �k �jc�,.�Cross Street City W r Zip Z Parcel# <br /> PROPERTY Owner�Q��CaGL Address City Zsp Phone# <br /> i� 44 i Address Ity Hary ` zip uc# Phone#°rte 31�_ app <br /> C-57 Contractor 1y <br /> Consultant/Sub Contractor cityS ( c#�Phanel `�6�—I 0®b <br /> GIS Coordinates:X YTownship Range Section <br /> WORK TO BE PERFORMED` <br /> n NEW WELL/BORING( P ,GEOPROBE,HYDROPUNCH,.HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> &SOIL BORING# U1 — - n OVER-BORE' <br /> ©WELL# U PRESSURE GROUT <br /> "Other Grout S ecifiptions: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICA IONS <br /> U MONITORING I]HOLLOW STEM DIA.OF BOREHOLE Z{� MULTIPLE CASINGS?1]YES II NO WELL CASING OIA:/V/a <br /> {]EXTRACTION IJ AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL n PVC j]OTHER: <br /> I]VAPOR i]MUD ROTARY DEPTH OF GROUT SEAT TREMIE TYPE TO BE USED: KAUGERS HOSE <br /> o AIR SPARGE RPUSH POINT GROUT SEAL PUMPED: res I]No (NOTE: MAXIMUM FREE-FALL DEPTH.,IS 30') <br /> Q SOIL BORING HAND AUGER GROUT SPECIFICATIONS: <br /> 'ROTHER: OTHER APPROX.BORING DEPTH- , []BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROP SED?_AIQ--(if YES,list specifications here): <br /> "COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE S OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN DVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the ork will be done in accordance with San Joaquin <br /> County Ordinances ales and Regulations,and all applicable Ca ifornia State Laws. A 11AA '' <br /> Signed x Tiile/Ca any � f <br /> Q "I <br /> Print Name Date <br /> DEPARTMENT U E ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> Application Accepted By ate Issued�( �A. <br /> Grout Inspection 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# tREC'D DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 02737 rales at o1-�BD <br /> g/27/00 <br /> C-57 W;­-WAIVER— C-57 Letter of Authorization sign permit Encroachment doc <br />