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WELL PERMIT APPLICATION FORM <br /> SITE <br /> MITIGATION <br /> C7�0 0 5 2001 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (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 and/or install the work described. This application is made in compliance with San <br /> Jo quip County Devel pment Title,C1 apter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> \�Cja (� :; S A t A Assessor's <br /> NELL Location ovk St p'f'Iirtl �o✓k S'1'. Cross Street 4*-o✓Q Sr:- City St -ktav� Zip Parcel# /39-2/0--o� <br /> PROPERTY Owner S''t'A+e ,P Cat:��art?k Address "f-- e- City l,a�' f3eA&A Zip 908,:2 Phone# <br /> C-57 Contractor iq/ooj LvezYci 0^1/j,1+ Address �S`D /[i Y6°�� �� City aSio V'fZiPic#7/oo) Phone#X07-379-`73�0 <br /> Consultant Sub ContractorCort .,.�,z.j1k /e,.4. _Address /8U' Fi--aNVt�dt'C,c6ity S1bc,v,-h sic# Phone# 23"/^oS78 <br /> du/f-e Z <br /> GIS Coordinates:X Y Township_f /� Range V ief- Section <br /> NORK TO BE PERFORMED: <br /> KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION(choose type below) <br /> SOIL BORING# IJ OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ <br /> KMONITORING FOLLOW STEM DIA.OF BOREHOLE 6 ri MULTIPLE CASINGS?Q YES )(NO WELL CASING DIA:o/�� <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESSS,-A 'YV TYPE OF CASING: O STEEL RPVC p OTHER: <br /> O VAPOR []MUD ROTARY DEPTH OF GROUT SEAL -:z S1—f TREMIE TYPE TO BE USED: AUGERS p HOSE <br /> p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes FNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neft'f- <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH `Y 7 ' BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?—,A/0 (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 Srtate/Laws. / <br /> Signed x � �!1�'-� Title/Company'rAZ�l- lrcc�+�ZiJf'/�r�a4e. L=c�,. t`b /Gi1rru4 lei <br /> 1, r.l-� <br /> Print Name DEPARTMENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE, ADDRESS: a S :.)-- Lt--s <br /> WORK PLAN DATED: �� A� ' A-a/- ( L(3 1 - <br /> Application Accepted By Date Issued l z�(o zb -Area- <br /> Grout <br /> reaGrout Inspection By Date Z' 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'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C2� n c I 1 -1 )th� . ZR293-69 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />