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� - � LIQ,,, WELAERMIT APPLICATION F*M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> uEC ���3 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> BVIROh1,j4'�1dl kjE " 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PFRNIT/SFS'(/" " (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> \ppiication 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 /> oaquin County Development Tide,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> j;dr Assessors Mn� <br /> VELL Location �Sl J ' t�__Cross Street t/1/,r��rx/C4 s Zp ✓�2 Parcel#�"rn[7[l—ZI <br /> 'ROPERTY Owner I.MAI4/ ,IIx �G/IIR4 Address�5/75��77! A 1 Cityziplr iPhon .;r <br /> -57 Contractor f 11Address <br /> ' (i ! City ,/b-Z'�p.r-�lslU <br /> ;onsultant/Sub Cntrf&V Address Cit,,4W!IY Lic#6Aj 7 Phone## <br /> 3IS Coordinates:X ,Y Township _ Range Section <br /> NORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 'DESTRUCTION(choose type below) <br /> 0 SOIL BORING# ROVER-BORE <br /> 0 WELL# n f,- J�— �� �E ROU <br /> ,Other - I GroutSpecifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BCREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?a WELL CASING DIA:_ <br /> ��EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: p OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Regulations, and all applicable California State Laws. <br /> 40 <br /> Signed z Tide/Company <br /> Print Name // �/ ���k�,` Date <br /> DEPARTMENT USE O�N�LYI � a <br /> SITE MAP IN UNIT IV FILE,AD RES : J I <br /> WORK PLAN DATED' ACT <br /> t� Date Issued 1� a Area / 7 a <br /> Application Accepted By _ �De_ea <br /> Grout Inspection ey Date F I Inspecdon By <br /> Destruction Inspection By r Date Q <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> S/29/02 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />