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.. <br /> WEL PERMIT APPLI ATION 'k. ORM SITE <br /> ti MITIGATION <br /> SAN JOAQUIN COUNTY PUBLI HEALTH SERVICES <br /> OCT 3 2 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD). UNIT IV <br /> "30E. Weber, Third Floor, S ckton, CA., 95202 <br /> (209) 468-3,e 49 <br /> PERI�IiT <br /> "NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor inst It the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 4.1115.3 and-the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> t Assessor's <br /> WELL Location ��0� `l�• VRAM-2 aA4,\4� Cmss Street City –O 3p2SLLZ-TParcel# <br /> PROPERTIOwner ll Address City Zip Phone# <br /> C-57 Contrador �14i Address A City Mp Lick. Phone#ki <br /> C�L c# <br /> Consultant/Sub Contrador u t4�s tY Phon � <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED" <br /> �[NEW WELL.!BORING( GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) []DESTRUCTION(choose type below) <br /> SOIL BORING# C. – [I OVER-BORE <br /> a WELL# [}PRESSURE GROUT <br /> 'Other. GroutSpecifications- <br /> COMMENTS: <br /> Tyk OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC TIONS <br /> MONITORING Q HOLLOW STEM DIA OF BOREHOLE Z MULTIPLE CASINGS?a YES []NO WELL CASING OiA:NA <br /> 0 EXTRACTION []AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 1]OTHER. <br /> [[VAPOR []MUD ROTARY DEPTH OF GROUT SEAL ' TREMIE TYPE TO BE USED: RAUGERS 11 HOSE. <br /> []AIR SPARGE RPUSH POINT GROUT SEAL PUMPED: q es� []No (NOTE: MAXIMUM FREE-FALL DEPTH'I5 301} <br /> 0 SOIL BORING a BAND AUGER GROUT SPECIFICATIONS: <br /> ' OTHER: C-(>T 1]OTHER APPROX•BORING DEPTH [�BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROI IOSED?__LQ—(it YES,list speciftratlons 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 ules and Regulations,and all applicable California State Laws. <br /> Signed x Ttle/Co pany if <br /> Print Name Date u l 100 <br /> DEPARTMENT USE ONLY " <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: � p <br /> Application Accepted By. m-jc �^ Date Issued_ <br /> Grout Inspection By Date nnal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMONS: <br /> ACCOLINTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTEE] CHECK* REC`D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> r' ' /cl2s acR# Fo�� B$z7 <br /> C-57 WG -WAIVEi2 C-57 Letter of Authorization to sign permit Encroachment doc 4/27/00 <br />