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Y <br /> _ ERMIT APPLICATION FORM SITE <br /> im <br /> MITIGATION <br /> 1 � _ ' Ir7� h <br /> SAN JOAQUIN COUNTY UNIT IV <br /> SEP1 6ZppZENTAL HEALTH DEPARTMENT (Ell <br /> 34 . Weber, Third Floor, Stockton , CA. , 95202 <br /> ENVIRONMENT HEALTH (209) 468 -3449 3 �IS <br /> PERMIT/SERVICES <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/ 2 <br /> Joaquin County Develoment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. I Irl <br /> It EAET JAV"crj 51 . 5 C� 7fG2 Assessors (Y7 - r <br /> 7A W EST JnUc(�,.1 F1 nn <br /> WELL Location Thr t! r74C 5 -/- Cross Street J.Ai� 6,4 City 57oC1�7�-I Zip 7SZ6 (P Parcel# ry7 - jLo - o4l <br /> a2 . Nas19I5s.TW 5T, 1sw4 y , a s3� ti <br /> ir <br /> PROPERTY Ow,,nelr L CA J .- a SAddress ?y_`;kST JA�u.(a^i 57. City �ToLKLay.( Zip 9S"' Phone# <br /> C-57 Contractor\Alk"( I�Z/thf}'� Address 3233 G, it/.n4�_eLf151. 514_(3City�r A ZipO'/� 7�LLic# S*Zf Phone# Cy_` wi <br /> Consultant / Sub Cntr �� / Address �d37 117 . CityTw Lic#(0& 227 Phone#C `U + 7 -IogO f° <br /> GIS Coordinates: X., y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # 0 OVER-BORE <br /> ZWELL # Al Ill / MW - 9 0PRESSURE GROUT <br /> `Other: ou/ Specif cations: <br /> COMMENTS - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , . <br /> `MONITORING HOLLOW STEM DIA. OF BOREHOLE ' "AK I' MULTIPLE CASING ?MULTI-LEVELS WELL CASING DIA: I. 7 rr <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS�Y— TYPE OF CASI 0 PVCOTHER: -r'ff(O / <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ZJ TREMIE TYPE TO BE USED: 'AUGERS 0 HOSE <br /> 0 AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: KYes 0 No (NOTE : MAXIMUM FREE-FALL DEPTH IS 30) <br /> 0 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTHS OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 7 CONDUCTOR CASING PROPOSED? ill ( if YES, list specifications here): <br /> - <br /> "COMMENTS: J� I Ill I'V L(I Cd Ar-yi C(l n^ o1-I fjaA (4 11,4-4t <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 O an es, Rules d Regulations, and all applicable California State Laws. / <br /> Signed x I Title/Company5'rA � &it) L ADly��� l/t'I� �GN V1 Q+<a/�ti-�A/tAL <br /> Print Name L_ D 4coll Date �`1��(d �2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : oll S. �it �P <br /> WORK PLAN DATED : 5` -0 ?. <br /> Date Issue ® Area <br /> Application Accepted 8y <br /> Grout Inspection 8y Date Final Inspection y Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: :WEXI 2:v �W 02m <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # R CID BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 0031Z3 (o <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Enncroach doc Cil 8/29/02 <br />