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• <br /> ELL PERMIT APPLICATION FORM SITE <br /> W <br /> SAN JOAQUIN COUNTY MITIGATION <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH gtoPkton CA T952 62) <br /> -�� 04 E. Weber, Third Floor, <br /> P (209) 468-3449 <br /> LED <br /> application is made in compliance with San <br /> o <br /> NON-REFUNDABLE PERMIT <br /> EXPIRES <br /> YEAR <br /> M DATE <br /> This <br /> te� made to San Joaquin County for a pAssessors <br /> SSL <br /> ndio <br /> Application is he y parcel# l3 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health pDep=m <br /> G 5Cross Street U <br /> WELL location �� / _ /' / City_s_ Z(�phone# <br /> PROPERTY LZ,eS�r / Address � y/��6 iphone# 6 <br /> C yLi��l Lic#___ <br /> Owner � City �c <br /> � c <br /> �GTc�Gi^ <br /> Addresso2 <br /> C-57 Contractor - Tj� City Lic# <br /> j/` k FcL�� Address1YJ- L <br /> Consultant 1 Sub Cntr Range Section <br /> Y ,Township <br /> GIS Coordinates:X e below <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type ) <br /> 0 OVER BORE. DIAMETER <br /> �,[1�EW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER`) 0 PRESSURE GROUT <br /> �"� 0 SOIL BORING# - GROUT SPECIFICATIONS <br /> WELL# l i <br /> 0 Other <br /> COMMENTS: <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MULTI-LEVEL WELL CASING DIA: <br /> TYPES�L DIA.OF.BOREHOLE� 0 MULTIPLE CASINGS 0 <br /> MONITORING HOLLOW STEM � r <br /> 1` PVC 0 OTHER: <br /> l� TYPE OF CASING: 0 STEEL <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: $AUGERS o HOSE <br /> 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 VAPOR o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30' <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes 74_� 'aK�0or 0 STOVEPIPE <br /> HAND AUGER GROUT SPECIFICATIONS �,SOLTED TRAFFIC BOX <br /> 0 SOIL BORING 0 <br /> 0 OTHER: 0 OTHERAPPROX.BORING DEPTH- ,t J� (if YES,list specifications in comment section) <br /> CONDUCTOR CASING PROPOSED�y- <br /> COMMENTS: S�cb <br /> -i ,-L'}- c '1 <br /> NOTE: OFFSITE <br /> BORINGS REQUIRE RE NC�ROACHMENT PERM/ <br /> E ACCESS AGREEMENT <br /> q8 WORKING HOURS NOTICE REQUIRED FOR INS <br /> cern that I have prepared this application and that the work will be done in accordance with S a <br /> I hereby fY <br /> County Ordinances, Rules and Regulations, and all applicable California StateLaws. �f <br /> Title/Company <br /> Signed x Date <br /> Print Name L <br /> DEPARTM�N�USE ONLY <br /> St <br /> SITE MAP IN UNIT IV FILE ADDRESS:—CL-4-1 <br /> WORK PLAN DATED: O 0 z/ <br /> Date Issued PArea` <br /> Application Accepted By r' e <br /> 1�_A.__ � Date 2.b C Finallnspection y <br /> Grout Inspection By Date <br /> Destruction Inspection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD BY DATE PERMIT I SER CE REQUEST# INVOICE <br /> 9/30. <br /> C-57_ WC—WAIVER_ C-57 Letter of Authorization tO sign permit_Encroachment doc <br />