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WELIPOERMIT APPLICATION 06RM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT/ <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) , <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON PERU EXPIRES 1 YEAR FROM DATE_ISSUED �" 1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made incornplia4.kh Sang <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Divisl4A. <br /> a Q�G,r1�h Assessor <br /> WELL Location CriM <br /> CI Ziop b deS�_Parcei#�1 qj <br /> PROPERTY Owne dresW W Ci p� P� i '1 I- Ltlr7� <br /> C-57 Contracto���?._Address 01 _Ci m ho ip 1, fuc hon <br /> O <br /> Consultant I Sub Contractor .`'�i AddressCi ' hon <br /> t nm <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> �IEW WELL t BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> SOIL BORING OVER-BORE <br /> 11 WELL# Q PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENT& <br /> TYPE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?(I YES (l NO WELL CASING DIA: <br /> p EXTRACTION (I AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 1)STEEL 11 PVC a OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 11 AUGERS [I HOSE <br /> 11 AIR SPARGE 1]PUSH POINT GROUT SEAL PUMPED: Q Yes Il No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> L BORING a HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: a OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or u STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> -COMMENTS: ff—9'-M� htsyi � QX jP (XC,J'iQA L.4 <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 nances, Rules d Regulations,and all applicable California State Laws. <br /> TI11e/Company���lA1�C��.���[ `^C.l�a-i— <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued x'10 b Area 1400 <br /> Grout Inspection By I"&-�A.C/( Date 4WI-I 140 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMIITTED CHECK it REC'D BYFfv <br /> TE �o6 <br /> PERMIT/SERVICE REQUEST# *4VOICE <br /> 3So S- a o�riq�sa ! t - Sam oo';-q?& <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit—Encroachment doc` 9/27/00 <br /> E0 39Vd 6DOId HIJIA 66068906OZ 16:61 8002/00/ZZ <br />