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k <br /> N <br /> APPLICATIOFOIRM <br /> - WELL PERMIT !� SITE <br /> MIT]GATION <br /> SAN JOAQUIN COUNTY .k . ..F.� ,I.. �a�I <br /> ENVIRONMENTAL. HEALTH DEPARTIVI�NT (,EHD���.lt..nk�"n <br /> 304 E. Weber, Third Floor, Stockton, CA, 952Q2 <br /> (209) 468-3449 J U L 17 Z40Z <br /> ' NON,99EMNPAULE PeRMTr EXPIREs'1 YEAR FROM ELATE I SM WhuwENT HEALTH <br /> Mppikatlon is hereby made to San Joaquin County for a permit to construct and/or install the work dasnAbed. IThis app 1 nce with San <br /> loaquln County Development Tice.Chapter 9-1115.3 and ft Standards of SsM. oaquin County Environmental Health�+� <br /> Artsess0r+9 <br /> NEIL Lucatlart o2 Cress Street �*� Ckty ZtpG e 3 _Parra�liJt /� <br /> PROPERTY owner ''{�7y!i SS <br /> '.47 Contractor / 1 drau � � qt ��p� �llane# .Zyo <br /> - <br /> :onsultant/Sub CorMraGor, Address ,_,,,_„^ City,, Y r„Uc Phone# <br /> I <br /> SIS Coordinates:X ,Y Townsnlp Rangel Section <br /> I NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,RANO-AUGP-t,OTHER-) DESTRUCTION(choose type 6efgrw) x <br /> OVER-BORE <br /> [`b�#ORING# j U PRE8SUt2E GRgtJT <br /> Otbar: Grout Spedflomilorw-i - --- <br /> :OMMENTS: <br /> YPE OF WELL INS'TALLAMN TYPE r,.gN4TgUCTION SPECIFICATIONS <br /> k I MONITORING a HOLLOW STEM DIA.OF BOREHOLE n LT1PLE=CASINGS?a 1'E3 9NO WELL CASING DIA <br /> ij I EXTRACTION a AIR HAMMERMRNQd CASING THICKNE=SS TYPEDF CASING., a STEEL_ []PVC 11 O'THER-, <br /> � <br /> ] <br /> VAPOR. Q MUD ROTARY 00-M OF GROUT SIZAI.._. .... �TREMIE,F TYPE TO 8E USED. [I AUGERS 0 HOSE <br /> AIR SPARGE „f<USN POINT GROUT SEAL PUMPED: l3 Yea (I No (NOTE:'. AXIMUM FREE-FALL 13EPTH IS 30') <br /> '$OIL BORING p HAND AUGER GROUT SPECIFICATIONS. <br /> „. <br /> ft OTHER APPROX,BORING DEPTH ___ _..---�I�Ij BOLTED TRAFFIC BOX or U STOVE PIPE .� <br /> GONDUCTC4 CASING PROPOSED? {If,Y ES,Sst specifications here/ <br /> / <br /> COMMENTS. 0L <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> t CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE! ALL REQUIRED INSPECTIONS. <br /> hereby car”that l have prepared this application and that the work will be done in accordance with San,loaquin <br /> ',ounty Ordlnances, ules nd Regulations,and all applicable California State Laws. <br /> .Igned�c // 'ritlelCampany �� ; �' <br /> orint Nome R,.*r trt Date 7} <br /> DEPARTMENT..USE ONLY . r <br /> .trrE MAP IN UNrT IV FILE,ADDRESS: <br /> WORK PLAN OATED: i <br /> { <br /> ay ' 4 • <br /> PlHicatlon 7 a v Area Y <br /> Jvut Inspedlorl By I]ate "Final Inspegn By ! Dale <br /> estruction Inspection By [>sta I; ill <br /> OMMEM I CONDITIONS-. I ! <br /> ACCOUNTING ONLY: AID# Cam <br /> PE CODES FIE INFO AMOUNT REMITTED CHECK# REC-D BY nATE I PERNIrr!SERvicF,IgFquEsT 4 w4olcE <br /> :-57 WC -WAIVER-__ - C-57 Letter of Authorization tO sign permit Encroachrnent cEOc 1/25/02 <br /> ZO 39vd NOiADOlS 39V 8TTTL9VG0Z 81:01 Z00Z/8T/L0 <br />