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6 19 <br /> ,( Ew-310 o/514 Fil1 <br /> WELLIERMIT APPL16ATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> A'JG 2 7 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENViUf'J�';�i!1 hE_ACfH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 �Fisde <br /> � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application in compliance with San <br /> Joaquin County Development Title,Chapter 911 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> WELL Location <br /> r0 2' N6 CiAssessor's <br /> Cross Streetip Parcel# <br /> PROPERTYOwner Fry oP JT!64& o^r Address Y2S-/✓E,(AAawOA S• CitySf, a, T74+l Zip9510z.. Phone# 2011 82Y 9Z/ <br /> C-57Contractor &j(,[ea O^uour^4 Address R0. Citylce�rZ0rfft Zip9TY7! Lic# Ili}L8/ Phone#46; SYL ,? <br /> 3Z <br /> Consultant/Sub Contractor LF/C &01^f r^^ur6' Address/910 4.,eu-S, IrNF City ' <br /> ��✓i�Cf Lic#��Phone#510 45? /rD0 <br /> GIS Coordinates:X .Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> �IQEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 W ELL# 6rw-30A 0 PRESSURE GROUT <br /> *Other; _ Grout Specifications: <br /> COMMENTS Ar) E cam? />L W <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING p HOLLOW STEM DIA OF BOREHOLE le.�MULTIPLE CASINGS?0 YESXINO WELL CASING DIA: 6 <br /> ;fQXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Jcli 00 TYPE OF CASING: a STEEL_f-PVC 0 OTHER: <br /> p VAPOR -)"UD ROTARY DEPTH OF GROUT SEALO-30-30 ' TREMIE TYPE TO BE USED: p AUGERS Z'HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: .8--Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: A16A7' r4s+6Alr <br /> p OTHER: a OTHER APPROX.BORING DEPTH 90' -BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> � 57 <br /> /�� CONDUCTOR CASING PROPOSED?�_(if YES,list specifications here): <br /> 'COMMENTS: lil�� <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 and Regulations, and all applicable California State Laws. <br /> Signed Title/Company f 1z4,Zer ��O/1oG Nt0G^tj U'>2 <br /> Print Name 7Atil �w/`lL-'^�- Date t�l-e <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: P� r 79#36 /a` <br /> WORK PLAN DATED: / /MAIM 7// / <br /> Application Accepted By �� r^ Date Issued Ar <br /> Grout Inspection By Date_ Final Inspection B ti Data <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS, <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 240 ► ! Cnn5f3 (o Iz gFe&' <br /> C-57_ WC=WAIVER= C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />