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FOR DD WELL PERMIT APPLICATIONR SITE <br /> MITIGATION <br /> 0EG 0 4 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRDIN,IE�T HErMH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> appllcation 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 9-1115.3 and the Standards of San Joaquin County Public Health Services,EnvironmenAssessor'sl Health�v� 1 O 0 <br /> S 5 wl °l`� Cross Street City Zip Pan eI# Z$ <br /> NELL Location p <br /> (� 35 Phone# 5 5 1 C <br /> PROPERTY Own ar \� °��� --_t5 Address \�l T- \ D S� City � S, Zip C/ <br /> { �{ Address <br /> X 6 CityTS� f r" Zip�Lic# <br /> C-57 actor Phone#a S 2L <br /> Consultant Sub Contractor C�z��o�" S� <br /> Y <br /> Township Range Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type beiow) <br /> a NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER`) �OVER-BORE <br /> &SOIL BORING# PRESSURE GROUT <br /> 0 WELL# Grout Specifications: <br /> "Other. <br /> COMMENTS: — $ 3 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATt NS <br /> MULTIPLE CASINGS?D-YE S a NOS _WELL CASING DIA: <br /> []MONITORING p HOLLOW STEM DIA.OF BOREHOLE OTHER: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC.,.01. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL'` j-n - TREMIE TYPE TO BE US`-lDV b�W�ERS 0 HOSE <br /> 0 AIR SPARGE RUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING I HAND AUGER. GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or o STOVE PIPE <br /> 0 07H=R:__0 OTHERS_ APPROX.BORING DEPTH D <br /> ONDUCTOR C ING PROPOSED? (If YES,list specifications here): <br /> *COMMENTS: 1G — ���� <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 herebytcertify that I have p epared this application and that the work will be done in accordance with San Joaquin" <br /> Countyanc s,R es nd Regulations,and all applicable California State Laws.TitlelCompanv C <br /> Signed x1l\�bt", DatePrintivamDEPARTMENT USE ONLY <br /> 5 !�w 5 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: It <'d 0 <br /> Date Issued Area <br /> Application Accepted By Final Inspection By ?� O 3 Date l <br /> Grout Inspection By­ Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID#, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 7REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE--------I <br /> OI<Z({ f I / 03 36 00 <br /> C-57--__ WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc 9/27/00 <br /> co 30vcd EbE89b6aZ 9S:ET T00z/qz/ze <br />