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MUM <br /> C,cW <br /> (t WELL PERMIT APPLICATION F M SITE <br /> — Z!o <br /> ( �, 33j MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> AUG 2 7 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 , Coi 5 <br /> C, i 1", -," ' HEALTH <br /> (209) 468-3449 <br /> EN\ <br /> r <br /> t tJICcS <br /> NON-REFUNDABLE PER EXPIRES 1 YEAR FROM DATE ISSUED <br /> described. This application is made in compliance with San <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work <br /> Joaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Env ironmenAssessor's Division. <br /> WELL Location <br /> 6pZ.. (oSLLAta�LCDWCross Street �'' i City Zip Parcel# <br /> PROPERTY Owner er�Y of rTd LKyDN Address Y2.T'/1/E�Qiwod S• City St0+x7//�✓ Zip 95 toz Phone# Zoo 82`1 4zG8 <br /> C-57 Contractor &kaLq ce zji, Address R O 130k 174 <br /> Cil <br /> Consultant/ <br /> ZIp5'y73 Lic# fj}C8/ Phone#1O� SyL 3L�Z <br /> Consultant/Sub Contractor (fQ Address/9rA P/N«" . /rN/`CIry� +'7'• Lic# ✓r� Phone#.i�0 65L /rOD <br /> GIS Coordinates:X <br /> y.,TownshipRange Section <br /> WORK TO BE PERFORMED: a DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a OVER-BORE <br /> Q SOIL BORING# a PRESSURE GROUT <br /> SWELL# 2 <br /> •f 7 Grout Specifications: <br /> COMMENTS: 't 3� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLE1'7-'ZS— MULTIPLE CASINGS?BYES)bNO W ELL CASING DIA: ti <br /> 6 <br /> EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS L 00 TYPE OF CASING: 0 STEEL QVC 0 OTHER: <br /> U VAPOR �tUD ROTARY DEPTH OF GROUT SEAL 0 —40' TREMIE TYPE TO BE USED: D AUGERS �WOSE <br /> -FALL DEPTH IS 30') <br /> a AIR SPARGE O PUSH POINT GROUT SEAL PUMPED:_kYes B No (NOTE: MAXIMUM FREE <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: NEN> " BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> p OTHER: O OTHER APPROX.BORING DEPTH 120' <br /> CONDUCTOR CASING PROPOSED? F/ (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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules <br /> and Regulations,and all applicable California State Laws. <br /> � <br /> Signed x Tide/Company <br /> Date r/ >��/ <br /> Pdnwame 1:)A,l DEPARTMEEN,TT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Area �7� <br /> Date Issued l ' <br /> Application Accepted By DateFinal Inspection B Date <br /> Grout Inspection By <br /> Destruction Inspection By Date <br /> vi-3/lir <br /> COMMENTS/CONDITIONS- <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 24 o NU,J 651310 0 3 <br /> C-5 — WC=WAIVER—� C-57 Letter of Authorization to sign permit ✓Encroachment doc_ 9/27/00 <br />