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v Cm Y <br /> WELL , ERMIT APPLICATION FL . .M g <br /> MITIGATION <br /> N� ' !I?r)t1� T � kVICFi.�li SANJOAQUINCOUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 03 DEC 38 PM 3' 4�1 304 E . Weber, Third Floor, Stockton , CA. , 95202 - <br /> 0�� (209 ) 468 -3449 <br /> J NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ypplicafion 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 /> loaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department �, 34 <br /> "AAWC Iv47 _ - Assessors //- wZ3444 <br /> NELL Location POLIS W � CNARTFr Wfl rocs Streef rN`�1v '1 IORf�e. City 51CfOKTOr ZZp Parcel# L� <br /> —Ta cK Tyr. 5 0 ! 5v A (, 5 3556 <br /> 3ROPERTY Owner .f l9fr Tf N6MeNtPri Address /' � � PIpR 1 q4 City T To n/ ZIP Phone# 20 ' <br /> C-57 Contractor � nv. GRey�r Address 9 'sP NAWG RoA� CityMAf7i+lPlZ!PyySf� Li �Phone# 4z5 <br /> :onsultant / Sub Cntr !! � � • � ' Address ? S4fjt.✓ Ab Cfiys / oC. I� T�+ Lic# 0822� 7 PhoneAi9 %) YV 7 ( 00 <br /> 31S Coordinates: X , Y Township Range Section <br /> NORK TO BE PERFORMED: ' <br /> NEW WELL / BORING CP GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') p DESTRUCTION (choose type below) <br /> •ASOIL BORING # CDT -•) I__ T a -CET4'3 ) CO%�yn PRESSURE GROUT <br /> O ('7�A <br /> p WELL 7IJ <br /> ,Other. Grout Specifications: n TrO� <br /> 30MMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Q //// MULTIPLE CASINGS? a MULTI-LEVEL? 0 WELL CASING DIA: <br /> ] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NjiAr_ TYPE OF CASING: ]] STEEL 0 PVC 0 OTHER: <br /> ] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I O O f TREMIE TYPE TO BE USED: D AUGERS `HOSE <br /> ] AIR SPARGE / Ozon2 PUSH POINT GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: bf 7_14 O T� DE !Y <br /> OTHER: 0 OTHER APPROX, BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C• 1 v CON/DUICTOR CASING PR OSED? �' ( if YES, list specifimbons here): <br /> `COMMENTS: N IY Q�£N�Vrn IR JVN� 7. .n n3 <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 Californi tate Laws. <br /> Signed x 77 e Title/Company <br /> Print Name r .Mo ht / V C V C LLQ'/� Date ©� <br /> DEPARTMENT U/SEE�O�NLLY , 1� <br /> SITE MAP IN UNIT IV FILE, ADD, ESS : <br /> WORK PLAN DATED : <br /> Application Accepted By Date Issued N ` it ; t . : ; Area D " <br /> Grout Inspection By _Date Final Inspection By � t�-- <br /> Destruction Inspection By - Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> ! �P9 <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 8/29/02 <br />