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WELL PAMI oAPPLICATION CFORA SITE MITIGATION <br /> SAN J <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ■ <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ca;93= <br /> y made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br /> '� � � � Assessors <br /> uincavelopment Title,Chapter 9-1115.3 and the Standards San Joaquin C//ounty Environmental Health Departmen d Y �1 /YQC�City�Z'P Parce/f/1�Xr h�--kfl/l KCl Cross StreetL � r,, /'/ l' / ( (/� Phone# S1-4b3/e `I�If'�iNpllkG`/Address �S/JSE'iY'iH�l/f�/ CitYS�KIl ZipZJ�/lY7fi'!l�/n�t� GG/ 1 city�ip� '��ue#67ZE✓ PhoneCAddress // �AddressCit Lic#(Oti�ZZ Phone# V <br /> sCntr Section <br /> Township Range <br /> Coordinates:X_�Yom_ �QN*Ld <br /> RK TO BE PERFORMED: DESTRUCTION yl-choose ty el below) <br /> IEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,,HAND-AUGER,OTHER") R-BORE. DIAMETER <br /> p SOIL BORT e r�4h iSl W—I4 (4) p PRESSURE GROUT je _ / /�. <br /> 'WELL# GROUT SPECIFICATIONS �i <br /> p"Other <br /> )MMENTS: <br /> ?E OF WELL INSTALLS TYPE CONSTRUCTION SPECIFICATIONS <br /> AONITORING HOLLOW STEM DIA.OF BOREHOLF,&t I],{M��ULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: 2/ <br /> AIR HAMMER/DRIVEN CASING THICKNES !S. A� ,_^TYPE OF CASING: a STEEL PVC a OTHER: <br /> _XTRACTION �—TREMIE TYPE TO BE USED: ,AUGERS Q HOSE <br /> ✓APOR a MUD ROTARY DEPTH OF GROUT SEAL �I�I <br /> 41R SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes <br /> a No (NO��KAX I%J�EO DEPTH�� I <br /> HAND AUGER GROUT SPECIFICATION r— T <br /> Aj <br /> SOIL BORING 0 �dBOLTED TRAFFIC BOX or STOVE tier <br /> OTHER CONDUCTOR <br /> .BORING DEPTHS if YES,list specifications in comment section) <br /> OTHER: O CONDUCTOR CASING PROPOSED NU <br /> OMMENTS: 3 <br /> I 0 }etl <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERM( <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <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. I 6 <br /> I Title/Company f2l CE) <br /> Signed x / t Date U <br /> I"in,t Name > I ti Q ` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD E <br /> 5135 <br /> WORK PLAN DATED: �3 <br /> Area <br /> t Date Issued g <br /> Application Accepted By Date! Final Inspection By <br /> Date <br /> Grout Inspection By 1S 1 Date <br /> Destruction Inspection By <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# RVICE <br /> PE CODES FEE INFO AMOUNT REMITTED CHEECK# REC'D BY DATE PERMISR#T I SEI <br /> /. ql REQUEST# INVOICE <br /> � l� a-3 U1 9/30/02 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />