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-•"ill a :moi <br /> WELIJL:'ERMI ' '� <br /> T APPLICATION FARM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> I ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 FILE <br /> COPY <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 19-11`15.3 and the Standards of San Joaquin County Public Health Services,Environmental Health'Division.. <br /> WELL Location f l2a�C. 'plu(}, solls <br /> Crass Street_ta�ig�c Q� City �,r C Zip sj7(o PAsses Z Z$ <br /> PROPERTY Own <br /> C-57 Contractor C. Dir/Address oa 30 C�ty� ty 36 o _ �� S <br /> Ck� <br /> consultant/Sub Contractor �[�12,. Address 3� ��� ��� City�Cartc�, ' Lic#.�a Phone# — Q � <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED- <br /> 0 NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER')' _. �DESTRUCTION(choose type below)• <br /> " - <br /> SOIL BORING#� . Q OVER'-BORE <br /> 'Other: [I WELL# <br /> []PRESSURE GROUT <br /> Grout SpeClfications: <br /> COMMENTS: Ol1Si Ron�tn e,\ I�a,S_t- _VVt <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING [I HOLLOW STEM DIA.OF BOREHOLE � V.%0 MULTIPLE CASINGS?[I YESWELL CASIING DIA:Q/4 <br /> (]EXTRACTION v AIR HAMMERIDRIVEN CASING THICKNESS Pa TYPE OF CASING: []ST'EEL [IPVC 11 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_ �A TREMIE TYPE TO BE USED: [AUGERS, 0 HOSE <br /> 11 AIR SPARGE i]PUSH POINT GROUT SEAL PUMPED: Yes �Na (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> '�QlL BORING 0 HAND AU-GER` GROUT SPECIFICATIONS: � <br /> D O``THER: OTHER �i?64_ �" APPROX.BORING DEPTHa BOLTED TRAFFIC BOX or d STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? � (if YES,list specifications here): - <br /> *COMMENTS: <br /> Ij <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, Ruies and Regulations, and all applicable California State Laws. ti # <br /> Signed x Title/Company S ECoQ-. `$ $p ct }n <br /> Print Name 1�. Q; 5;1�a, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: / <br /> r � F f <br /> Application Accepted By Date Issued O Area, <br /> Grout Inspection By Date Final lnspection By Date <br /> Destruction inspection By Date <br /> COMMENTS ICON DITIONS: ` <br /> ACCOUNTING ONLY: Ala# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC^-WAIVER C-57 Letter of Authorization to Sign permit Encroachment doc :; "9/27/00 <br /> E0 39bd 210073 HJ_dId EEVE89h60Z 16:CT 0002/b0/Zl <br />