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- I <br /> T APPLICATION FM SITE <br /> RFC��.�Iti`!� U WELL PERM <br /> ; <br /> MITIGATION <br /> Ir SAN .�OAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> MAR 15 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> I PERMIT/SERVICES (209) 468-3449 <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 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,Environmental Helth Division. <br /> ,1 ' <br /> Location 11 � - - - - - Cross Street Ma City Zip Parcel#t't' <br /> WELL Loc . 00 <br /> PROPERTY Owneress S _CCityJ _ C] -Y� / <br /> i -- „4•r,,! - 33. CityK�� Zi��� c#A Pfione#9�6o 4 'r Td 76 <br /> I C-57 Contractor Y Addresr� <br /> Consultant/Sub Contractor ti <br /> Address&A-2 S Gity Phone# �`" l/- <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 0 OVER-BORE <br /> I]SOIL BORING# <br /> WELL# ()PRESSURE GROUT <br /> "Other: q Grout Specifications: ;} <br /> COMMENTS: <br /> i� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �� y <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ' MULTIPLE CASINGS?I]YES k"O WELL CASING DIA: <br /> EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: [)STEEL 0,KC ]]OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_ 3 � � TREMIE TYPE TO BE USED: e-ADGERS 0 HOSE <br /> 0 AIR SPARGE 11 PUSH POINT GROUT SEAL PUMPED: 0 Yes �].Idg {N TE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �- <br /> 0 OTHER:_O OTHER APPROX.BORING DEPTH (4?Q= OLTED TRAFFIC BOX-or 0 STOVE PIPE <br /> n CO Du TOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: r •EW{ <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, Rufts and Regulations, and all applicable California State�Laws. AO) <br /> Signed xIrAA/ilITide/Companyz.C.! <br /> Print Name L Date 1 � -- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: '/571 <br /> WORK PLAN DATED: C �a l <br /> Application Accepted By ` ' `` Date Issued 0 Area <br /> Grout Inspection ByDate Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> "3501 SO 9. 00 <br /> C-57 WC -WAIVER C-57 Letter of Authc647dqmit Encroachment doc 9/27/00 <br />