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SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 FILE C <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 /> A' p � --�^ Assessor's <br /> WELL Location L 1 b V--V t"�3C(t1rL.1/�a.1 P11 OtC� Cross Street City 6 Ti" Zip�SA�?Parcel# 243-'�53�'Z- <br /> PROPERTYOwnerr//VAOAt UAAJ1rC_N Address 60Y45 City ll 'LSC°�_Z09374Phone# <br /> C-57 Contractor(,7,(",bYy (5+eCCbV Address c 27_t5j1a4 7City SInL.11rr� Zip S�/i-Lic# f-Phone# Q9 /t iJ�, <br /> Consultant/Sub Cntr A dvAv d Aw 6 a Address] 37.� /GGC Clty� Lic#6602Z 7 Phone# 00DIJ�j <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PER MED: <br /> NEW WELL EDC GE R�01,3HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> x # I 1]OVER-BORE <br /> n N/ELL# a PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE g MULTIPLE CASINGS?0 MULTI-LEVEL?Q WELL CASING DIA: 1 <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASINGTHICKNESS A- TYPE OF CASING: Q STEEL O PVC 0 OTHER: A11 <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL_--TREMIE TYPE TO BE USED: 0 AUGERS WHOSE <br /> 1]AIR SPARGE/Ozone,XPUSH POINT GROUT SEAL PUMPED: 0 Yes 1]No (NOTE: MAXIMUM IF�REF-FALL DEPTH 1S 3f') <br /> *QOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:Opt i�Li�iVe G �� �' <br /> /0 OTHER: (1 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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 /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Com an <br /> P y �e,c�i�x:ls-f II ��d/uA�e�I� C�eQ <br /> Print Name i�l 1t1 L K�L1M {� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 10-+ W- I3eye,,,Y j , Pl r eo} <br /> WORK PLAN DATED: Jan v a r 4 200 D <br /> Application Accepted By c1 r Date Issued 6__5 -Area—JAS <br /> Grout Inspection By Date G 1��l Final Inspection By ate_ <br /> Destruction Inspection By Date . <br /> COMMENTS/CONDITIONS: Drill ; <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 ,35-61 4 <br /> 95'.00 X89. 0 0 18688 Sr'Z ova zs� <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />