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WELERMIT APPLICATION FORM <br /> i �- � SITE <br /> � j.'�;I0 MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> MAY 1 4 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> _ <br /> r:IcI�� LTi 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> EfV�VI�:JIE:vi :rT.i1 (209) 468-3449 <br /> +1 <br /> Ll li. : 5,r 111JES ^1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application ism fian:withn <br /> Joaquin County Develo ment Title,Chapter 9-1115. d th Standards of S Jo m County Public Health Services,Environmental Health Division. <br /> uLITO Assessors <br /> i GJ �'KC2� S- z.Cc � ' <br /> WELL Location CrassQStreet V`IQCity 11 Zip Parcel# <br /> PROPERTY Owner% 1 p 16 Addddress Ci Zi �Qhone# 3?v� I <br /> C-57 Contractor ��T`l7�FL-„Address �233� � City Zipic Phone#9�� /7L7�O <br /> Consultant/Sub Contractor- 6,6 ,E+ Address�� . ) ity� ic# Phone# *71M7� <br /> GIS Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED: <br /> h EW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �3 DESTRUCTION(choose type below) <br /> []SOIL BORING# Q OVER-$ORE <br /> Il WELL# {I PRESSURE GROUT <br /> 'Other. Grout Specifications: , <br /> -OMMENTS: <br /> rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING o HOLLOW STEM DIA.OF BOREHOLE ULTIPLE CASINGS?II YES,-WeO WELL CASING DIA: °L <br /> ]EXTRACTION [l AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 1}STEEL _0.PLVC n OTHER: <br /> ]VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL '57 ftj�rTREMIE TYPE TO BE USED: 4UGERS Q HOSE <br /> ]AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Yes �(NOT�E. AXIMUM FREE-FALL DEPTH 1S 30') <br /> ]SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: <br /> ]OTHER: (I OTHER APPROX.BORING DEPTH 45 'moi OLTED TRAFFIC BOX or Q STOVE PIPE�� <br /> f��(�f CONDUCTOR CA ING PROPOSED? r�� (if ES,list specifications here): <br /> COMMENTS: llu��- '�� <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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> aunty Ordinances, Rules and Regulations, and all applicable California State Laws./7 <br /> Signed xIt <br /> / fJt,(,J�fG�_ _ Tide/Company <br /> ,'Tint Name { 1QJ Date <br /> DEPARTMENT USE ONLY <br /> ,;ITE MAP IN UNIT IV FILE,ADDRESS: J�Gr e <br /> NORK PLAN DATE �C <br /> i application Accepted B V U Date Issued t� fX) Area <br /> 3rout Inspection By <br /> ate D Final Inspection By U Date <br /> )estruction Inspection By D <br /> ate <br /> :OMMENTS I CONDITIONS. l1.1.0 n Lv- S �O <br /> ACCOUNTING ONLY: AID# QGI t r CL ` <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC Y- E PERMIT/SERVICE REQUEST# INVOICE <br /> 35 �9 1518 ( o Z 1 <br /> -57 WC -WAIVER C-57!tetter of Author izati 1s p it Encroachment doc 9/27/00 I� <br />