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San Joaquin County <br /> SITE <br /> ti L !L! ,,, !; ii ` <br /> J <br /> Environmental Health Dep'artmen <br /> 600 E. Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-343:)') Web: www.sj 2 �,C,07 <br /> gov.org/e� L <br /> UNIT IV <br /> ` <br /> WNM R,0 N 10 E NTell Permit Application E P <br /> I <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 9-111 5j-wd the_Sj�dards of San Joaquin County Environmental Health Department. <br /> Zip Assessors <br /> WELL Location V_Al Treet- S-6e��j city Sf kv Parrel# <br /> V <br /> PROPERTY CA + / defe6pe% ?"4 city. -SiCkW Zi45)/l Phone# <br /> Owner 'rrow(4 __P.A ddress /o/elo <br /> I . C517 <br /> C-57 Contractoraed-rum, Addres City 6l" Zipfr_�K-Lic#rI.V69 Phone# <br /> s WAA��Dr <br /> Consultant/Sub Cntr- 1-1 tfl IV7Cf DC I' Address 09,)5'r1'7-jd1e- City ylkW Liff Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> a SOIL BORING# D OVER-BORE. DIAMETER <br /> n WELL* - a PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMM?NTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS fJf <br /> a MONITORING -$HOLLOW STEM DIA.OF BOREHOLE. 19"1 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS SCk 0 TYPE OF CASING: a STEEL VC a OTHER: <br /> 0 VAPOR �P <br /> TREMIE TYPE TO BE USED: DAUGERS <br /> U MUD ROTARY DEPTH OF GROUT SEAL_ /0 _4600SE <br /> a AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )kYes allo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> BO N <br /> 0 SOIL G 0 HAND AUGER GROUT SPECIFICATIONS Nel- elel_e 17t_ <br /> )(OTHER: VIMM a OTHER APPROX.BORING DEPTH 3 a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A10 (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 and Reg�ations, and all applicable California State Laws. <br /> Signed x -Title/CompanyAle 1�(__14141�elaler <br /> Print NameralJ02 <br /> ;wv Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _/7 <br /> WORK PLAN DATED: 10 <br /> Application Accepted Date Issued-16 6 7Area 3 4/ 1 <br /> Grout Inspection By Yate %0 d jj!jA6A,, Final Inspection By Date TT <br /> Destruction Inspection By Date'� <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> lo S R#Le 7 <br /> C-57 . WCC WAIVEP, C-57 Letter of Authorization to Sign permit—Encroachment doc <br /> EHD 29-02-001 web <br /> 6122104 <br />