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WEE- .`" ERM1T APPLICATION FC!�M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) IT <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE 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 and/or 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 Environmental Health Department <br /> 1' n Assessor's <br /> WELL Location c���11� ii U-(X�tu_ �_�L_ Cross Strreet,^'1��Jr. city Zip 9 537�p Parcel# 2�nn- cam-2�, <br /> PROPERTY Owner <br /> ,//�•��'1°& I�yy' fsaO A�d+�dress � �� V��cVtVl�lLLStCity AC Zipg�376 Phone# Zb� D376��� <br /> C-57 Contractor4(,VM9(c:a64VE7!✓ Address U.a7��i1�GG�/�CS[,� nICity'siDGan Zip S�/ `Lic# Wwphone# �a /> � <br /> Consultant/Sub Cntr A d z**,Id 6ev 6u J Addresslls 375hC,f 4&2/[GC Clty& Lic#6i602Z Phone#A* "006 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PER MED: <br /> NEW WELL ORING (CPT, EO O HYDROP�INCH, AND-AUGE OTHER-) [I DESTRUCTION(choose type below) <br /> SOI ORING# OVER-BORE <br /> [I WELL# []PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING a HOLLOW STEM DIA.OF BOREHOLE oa/ MULTIPLE CASINGS?o MULTI-LEVEL?c WELL CASING DIA: ! <br /> I]EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS d_4 TYPE OF CASING: Q STEEL Q PVC a OTHER: <br /> 0 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED: 1]AUGERS ZHOSE <br /> D AIR SPARGE/Ozone x[PUSH POINT GROUT SEAL PUMPED: ❑Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3C') <br /> SOIL BORING `HAND AUGER GROUT SPECIFICATIONS:gotY &� —4k -�k � ��d <br /> ,0 OTHER: ❑OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AI& (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 /> Coun rdinances, Rules and Regulations, and all applicable California State Laws. 1 J <br /> Signed x / Title/Company 2 t y(L�I S�T r/_ duA1-Y-i I\ Ge o <br /> Print Name I;T—: L P'c vi, Date p �y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ 1 ,04 W. -Bever- l(,, Pl a C,e- i Ird Limit 4 <br /> WORK PLAN DATED: 0 0 <br /> Application Accepted By la. Date Issued .� (� Area /45- <br /> Grout Inspection By Date 0 Final Inspection By ate_�s f_1Q /D 3 <br /> Destruction Inspection By Date ! " <br /> COMMENTS/CONDITIONS:— C Z t' 8 S2. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY t?ATE PERMIT/SERVICE REQUEST# INVOICE <br /> 50 v89, o0 84o0 IgG R.F-- SR Oo34 f <br /> C-57 WC_-WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc 8/29/02 <br />