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WELI•'ERMIT APPLICATION F*M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 952020 r <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 2 2 2003 <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 ccr�p�llin��Gp W t pan <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Depar '�.RQ�jN1 tIN 1 rICH�I r'' <br /> WELL Location 640 N. E1Dorado Cross Street Park St. c;tyStockton Zp95202P ggq3ERVlCES <br /> PROPERTY OwnerGene Gabbard Inc. AddressP.O. Box 1260 cityStockton Zip95201Pnone(g209) 367-6992 <br /> C-97ContractorFisch Env. Address399 Sheris P1. cialley Z;pgR9FicCB3Zi5none#( 209)772-357G <br /> gE�rings <br /> Consultant/Sub Contractor Ground Zero Address 1714 Main Cigscalon Lic# Phonek2D91838-9888 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> $I EW WE /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> DWELL# MW-5':-MW-6 . MW-7 0PRESSURE GROUT <br /> 'Other: Grout Specifications:Neat Cement <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> RMONITORING 1j HOLLOW STEM DIA.OF BOREHOLE 8 a" MULTIPLE CASINGS?0 YES :R NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: 0 STEEL XMPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-15 r TREMIE TYPE TO BE USED:XjkAUGERS 0 HOSE <br /> p AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes XWo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING DHAND AUGER GROUT SPECIFICATIONS: Neat Cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 35-40 41 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (if YES,list specifications here): <br /> .COMMENTS: wt LA) S71nc�n I jQ,4CMy=, d-o �(n.,c anlx p� rl sup JA^ Alf- ,a.w� �,L� <br /> �ot%Q I�grt + 51&,1) <br /> NOTE: OFFSIT9 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 State Laws. <br /> Signed x_ _ '+`r. � Title/Company_ C vu—V0 -0exVj S IwL <br /> Print Name -LPnV,\Q- Z61 CP-7 9 S-_ Date_ A 1/03- <br /> DEPARTMENT USE ONLY 'L E` C <br /> SITE MAP IN UNIT IV FILE,ADq RESS: C,`�U N • C��P G��� --s <br /> WORK PLAN DATED: 9 P I D 2 <br /> Application Accepted By Date Issued 4 12,3 Area <br /> Grout Inspection By I A; r_.Fn Date 431Final Inspection By Date Z3 O T <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODESFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 Sol 91-0o 012-9 I I Ak I Hv3 0 I SR# 335 <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />