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WELL PE"IT APPLICATION FORA <br /> SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY P <br /> RTMENT (EHD .h_.no �a � <br /> ENVIRONMENTAL HEALTH DEPA <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 J U L 17 2002 <br /> ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED�NVIK,) vIEdeN�T� lti��rHEALTH w <br /> 4 Ipplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. 'This app I , * n vnce with San <br /> Joaquin County Development--ride,Chapter 9-9115.3 and the Standards of Sian Joaquin County Environmental Health <br /> (� C '} Assessor's <br /> YELL Location.1 Cross Streetde`S�fl Cityc� ZipParcel# <br /> 1 / <br /> 'ROPERTY Owner f"r r 12 - Addres O r`f'L�J �.Lt✓Zipq �4/ / Phone# 7�7 417`�' s <br /> : 7 Contrador�t114A�1 CSA v dress— - —City p 2I"c#bA4ZFhone# 4/67 `-'CCO <br /> :onsaltart/Sub Contractor "' AddressCity Lir,# Phone#. <br /> l� <br /> .IS Coordinates:X Y Township IRange Section <br /> YORK TO BE PERFORMED: <br /> I NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') I]DESTRUCTION(choose type below) <br /> 0%bIL BORING# tis r Q OVER-BORE <br /> ' 11 WELL# 0 PRESSURE GROUT <br /> Other: Grout Specifications: !I <br /> ;OMMENTS: I <br /> r � <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIo S �� 51,? 6 5 <br /> I MONITORING []HOLLOW STEM DIA.OF BOREHOLE ' LTIPLE,,CASINGS?1]YES A"'O WELL CASING DIA:_ I <br /> I EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CAS IhNG: o STEEL 1]PVC 11 OTHER: <br /> I VAPOR 1]MUD ROTARY DEPTH OF GROUT SEAL .�REMIErTYPE TO BE USED: [I AUGERS p HOSE <br /> I AIR SPARGE „3PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: `M` AXIMUM FREE-FALL DEPTH IS 30') <br /> ROIL BORING []HAND AUGER GROUT SPECIFICATIONS: ft !1 <br /> I OTHER: n OTHER APPROX.BORING DEPTH If I]13OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> / <br /> CONDUCTOR CASING PROP OSE <br /> I#D? (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. ' <br /> I <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. f <br /> i <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> igned x Title/Company 11 <br /> rant Name Bate <br /> DEPARTMENT USE ONLY. ! <br /> JTE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED' <br /> I <br /> pplication Accepted By Date Issued] ! Area <br /> Mut Inspection By. Date Final inspection By .;i Date I <br /> estruction Inspection By Date <br /> OMMENTS I CONDITIONS: I N <br /> ACCOUNTING ONLY, AID# <br /> eerir I� I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'O BY DATE �� PERMIT I SERVICE REQUEST# INVOICE <br /> 7 Iq -q R16 <br /> :-57 WC -WAIVER C-57 Letter of Authorization to sign permit l Encroachment doc 1/25/02 <br /> x � I <br />