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WELL PERMIT APPLICATION ARM SITE <br /> MITIGATION <br /> 1 = � SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> OCT 0 3 2002 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES 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 /> Assessors <br /> WELL Location Lq 11t° �� Cross StreetIN / //--c city Zip 7 Z� Parcel# �� <br /> i /�13S,L1-je �f1�'llle�'C� Citys,6(.�c�b9? Zip�SZ� Phone#ZP7 `!S!'02.4 <br /> PROPERTYOwner '"%y(iJl1�I�GI6//S/�IIT�y1,r Address <br /> t <br /> C-57 Contractor n r�rt. Addres?3ff fJ`1'qje,.kj#ju�CJtl City .A L'l:i`b+g4ip �s Phone# 91/p .s `727 <br /> Consultant/Sub Cntr Address <br /> GIs Coordinates:X <br /> y_,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> XNEW WELL/BORING(CPT.GEOPROSE,HYDROPI INr.H HAND-AUGER,OTHER') OVER-BORE <br /> r[SOIL BORING# 0 PRESSURE GROUT <br /> `Other: <br /> `WELL# 4IMLI < <br /> Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE b'.2Sn MULTIPLE CASINGS?1]MULTI-LEVEL?U WELL CASING DIA:2 <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 4.Lt.40 TYPE OF CASING: 0 STEEL KPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1'k 4W+ TREMIE TYPE TO BE USED: `};AUGERS o HOSE <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 11 8 n u <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH ��OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS4 6AtkL.W u=-ii' ice;" 66" ! ---`ek40 60 Pvc d'a� <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 /> 1 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. A� II <br /> Signed x <br /> Tde/Company �`e-L'�-L`U-�• <br /> Date IID' � I b2 <br /> Print Name_ , L�` l 1.,1100. "I`' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 41 <br /> p 1 / <br /> ��� �/ Date Issued 1 D 1 I `t I 0 Area Y'Z <br /> Application Accepted By A `�I�,�t � Date <br /> Grout Inspection By yn '" Dam O 0`Z Final Inspection By <br /> Destruction Inspection ey Date <br /> COMMENTS/CONOMONS:. 0 7 4A /Yt W <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a pIIn <br /> cl �`) I75a� �- aau6 �/ 3 11P5 <br /> 8/29/02 <br /> C-57_ INC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br />