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WELLk-,e,' APPLICATION F64. 11,14 SITE <br /> MITIGATION <br /> SAN JOAQUIN CO <br /> U NTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT N <br /> 304 E. Weber, Third Floor, Stockton CA.,1�95202 } <br /> M HEP�� (209) 468-3449 FILE COPS' � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application iVWy 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 /> 'i Assessor's ?, p <br /> WELL Location ��' "� Cross Street VA'1�rP� City,,�r �G zip �zd Parcel#� <br /> PROPERTY Owner It r / Address�� r�d ?+�P1�awdCi t Zi� 'C Phone# <br /> �Sl 7�i o _X/4o <br /> v � Ci G Zi E 7� Pho e# �3`� 1>'� <br /> C-57 Contracto Address / �1ty p <br /> Consultant/Sub Cntr ��� Address ?SGL J� Cibc_�_Lic# Ph Z16 71 LO� <br /> GIS Coordinates:X Y Township �i Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 17 DESTRUCTION(choose type below) <br /> a SOIL BORING# OVER-BORE <br /> 17 WELL# PRESSURE GROUT i <br /> "Other: Grout Specifications: <br /> COMMENTS M <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> G <br /> ,211ONITORING 21nOLLOW STEM DIA,OF BOREHOLE ''� LTIPLE�CASIN kS?H MULTI-LEVEL?9 WELL CASING DIA _ <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ©STEEL �VC Il OTHER: <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL XO TREMIE TYPE TO BE USED: B AUGERS ©HOSE I <br /> p AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED: 0 Yes 146 SNOT : MAXIMUM FREE-FALL DEPTH IS 30') j <br /> Q SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER 0 OTHER APPROX.BORING DEPTH r IF,� - - OLTED TRAFFIC BOX or p STOVE PIPE <br /> ., g,,,j CONDUCTOR CASING PROPOSED? �, ("if YES,list specifications here): � <br /> `i:OMMENTS• l�f r'+� 14 j4 61 6 j <br /> I} i� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. i <br /> I <br /> I hereby certify that I have prepared this application and that the work will be Clone in accordance with San Joaquin ! <br /> County Ordinances, Rules and Regulations, and all applicable California StateL7G' <br /> rlc- <br /> Signed <br /> Signed x Title/Company7�; �� ' r-s J <br /> Print NameDate ' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z44 Wesf Hard I n f� a L±oc k_--C> <br /> WORK PLAN DATED: 0& rehr,lgr&4 2003 <br /> Application Accepted B V i,n k I M 0�Y'+),1"4 Date Issued � ,� d Area- <br /> Grout <br /> reaGrout Inspection B ,i.Ls9��` e4kLf Ag, Date y= -1?� Final Inspection 1 ate �(-5(- 0 3 <br /> Destruction Inspection By 10, Date II <br /> COMMENTS/CONDITIONS: l PJY a S <br /> ,E <br /> [EACCOUNTING ONLY: AID# <br /> I .i <br /> S FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE l PERMIT/SERVICE REQUEST# INVOICE <br /> �89. ad 89.oa 1 3t3 I SR 00337-88 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment dot 8/29/02 <br /> lr <br /> I� <br />