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P�- zz 8Y <br /> P V-t b WELL RRMIT APPLICATION IF g <br /> �'� MITIGATION <br /> `E - �/ 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 <br /> ESI`:/IRO d;,F1\IT HIc LTH (209) 468-3449 �fF' Cos ) <br /> FERP�IIT/SERI ES Plc <br /> NON-REFUNDABLE llc- <br /> 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 is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11.t,15 Lnd th Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor <br /> WELL Location 630^68S Atpross Street yCity � � Zip Parcel# s <br /> 'Ruw <br /> PROPERTYOwner <br /> CrTY oP ST64K�o.v AddressYZr1VQ1AA,wvA f• City Sfa4,CrIJ Zip 57-z Phone# Z09 8214zc8 <br /> C-57 Contractor WF/•141 D2swy4 Address /0 O. /30L 176 Cityfsjnr Zip 9Sj;'J Lic# 1I}L81 Phone#1d� Z� 3L7z <br /> Consultant/Sub Contractor Lf2 Address 1940 P��✓fr�.11. IrN`Cityj6; Lic# wZ. Phone#.S/o 65L VfZ'o <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> AEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# U OVER-BORE <br /> IJTW ELL# 07-ZV 0 PRESSURE GROUT <br /> •OtherGrout Specin 0 <br /> COMMENTS: N �}ST 01 zzZ S <br /> *-7 2113 N -a0 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 7rONITORING 0 HOLLOW STEM DIA OF BOREHOLE /0.7r- MULTIPLE CASINGS?0 YES bNO WELL CASING DIA: Y r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5"04 Y6 TYPE OF CASING: 0 STEEL ,fPVC 0 OTHER: <br /> 0 VAPOR "UD ROTARY DEPTH OF GROUT SEAL O- 36 TREMIE TYPE TO BE USED: 0 AUGERS *HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 1,16,97 ^e, Ayr <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 9D ' ,)CBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N (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 and Regulations,and all applicable California State Laws.,, <br /> Signed x ��— 7fle/Company f ,A/ZQ.Etr �Y�OitoG N40Grj <br /> Print Name TAA Jr, Ara -x Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application AcceptedDate Issued � Area <br /> By <br /> Grout Inspection By Date Final Inspection B •.r Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: -3� <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNTREM CHECK# <br /> RECD BY DATE PER /SERVICE REQUEST# INVOICE <br /> Zoo Mu) 3 l042,1110) OZ8o5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/27/00 <br />