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ELLOERMIT APPLICATION MOM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> JUN 1 g 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ,d-VII-10 HEALTH (209) 468-3449 <br /> �3FRVICES 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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 f fi � :G Assessors <br /> WELL Location g$ fes' V���Or Fb 40I Cross Street"c - 'City 400 Zip�z"10 Parcel# I <br /> PROPERTY Owneerr5"kk i.R.r..�:, ,,r S;nG�A �(Q LJgif Le- CltySrtc*'o^. oZip9S' Phone#L�R <br /> C5G <br /> 7 Contractor �!Ae t� pddressZ�-r 1ji n4 Address `-'30' tLL'w-- tel- City r z Ip 553Uc#-YgSIGS Phone/# zs 3(3-5mc <br /> Consultant/Sub Cntr CO.146r Address P• __City <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: - <br /> $NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) H DESTRUCTION (choose type below) <br /> 0 SOIL BORING# a OVER-BORE. DIAMETER <br /> - <br /> WELL WELL# ht - I'3o �sr.J to M'11-11 aPRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I/ <br /> MONITORING `,gHOLLOW STEM DIA.OF 13OREHOLE-Lo r 0 MULTIPLE CASINGS 'Ci <br /> WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Sc1—B0 TYPE OF CASING: 0 STEEL , PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL '55" TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT SEAL PUMPED:` ,Yes p No (NOTE: MAXIMUM F�R/EE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS ' o 4 1.i oa Ge 1r2T C11- <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH I00 7 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 <br /> and Regulations, and all applicable California State Laws. <br /> Signed �� _ % ----- Title/Company-:5-" c� S4o-KGec6 is C4 r•i <br /> Print Name GG.,[, Moi...M; n� Date iZ 03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By '' Date Issued �w <br /> ;719 co a <br /> Grout Inspection By Date Final Inspection By Dan <br /> Destruction Inspection By Date <br /> Cj <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# EC'D BY DATEPERMIT/SERVICE REQUEST# INVOICE <br /> 3TD1 `3 . or) SR# <br /> C-57 WC WAIVER_ C-57 Letter of Authori o sign pe mit_ Encroachment doc 9/30/02 <br />