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i <br /> I WELL PERIIMIT APPLICATION FORNI SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNF , IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS -EHD) <br /> 304 E . Weber, Third' ]Floor, Stockton , CA., 95202 <br /> (209) 458-3449 O I 1 I V I <br /> ME <br /> NCN-REFUNCABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE? <br /> An-elication is hereby made to San Joaeuin County for a permit to construct and/or install the work described. This application is made in compiianca with San <br /> Joaquin County Development Title, Chapter 9-11155 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Assessors <br /> WELL Location -/ / GJ ��( C � � ' Z- "V z- Cross Street LOA ( k City S}ock&I Zip 75x0 '7 Parcai# <br /> PRCPERTYOwner �&Ii'y CLSkD Address %tS: RACrG 'L &J2- n/� CitysI�c.Lk✓t Zip /9s,Ao7 Phone# 5' 7K-s- V `I <br /> C-57 ContractorGrz T ✓`1 SinI�}U Address �S() �OWfO - R City l 'lAf� � n4,L�Zipy S3 Lic>/YlNG Phone#. 9�5# - 31B - sP� <br /> Consultant / Sub ContractorQLviceNLea E✓nv,l2vrlmr� lcl Address 837 y%mj RA City Sjoc kfeh Li�6,Ft? a2 Phone# Z/7U 7-10 <br /> GIS Coordinates: X . Y , Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> p NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH ._HAND-AUGER% OTHER') OVER-BOREtypeb <br /> SOIL BORING # P la - �%rs V <br /> WELL # Q PRESSURE GROUT <br /> *Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a HOLLOW STEM DIA OF BOREHOLE 2 Ln MULTIPLE CASINGS? U YES 1] NO WELL CASING DIA:_ <br /> EXTRACTION D AIR HAMM ER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 706 FT TREMIE TYPE TO BE USED: B AUGERS N HOSE <br /> p A <br /> AIR SP .�. <br /> SPARGE PUSH POINT <br /> GROUT SEAL PUMPED: Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ) <br /> N <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONS: <br /> 1] OTHER: N OTHER APPROX, BORING DEPTH IwFc Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> A nn CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br /> 'COMMENTS: & rin A L)6,ocrct' U (1111Z,n r C. PT rTccl'i (<b to <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O%ina es, Rulesand Regulations, and all applicable California State Laws. <br /> Signed x /� /� Title/CompanyEnorcj7me#461Pdnt NamefZ ���Iz" , \ � � Itr Dale <br /> DEPARTMENT USE ONLY . <br /> SITE MAP IN UNIT IV FILE, ADDRESS : I r/ � 1�oo <br /> WORK PLAN DATED : <br /> Application Accepted By Date Issued ea <br /> Grout Inspection B Date Final Inspection By ate • Z�o 'b <br /> P Y <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# _ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D- BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> to — / Q 0 2-6 <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_ - 9/27/00 <br />