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WELL = RMIT APPLICATION R Illi SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> V <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) a1T I ' <br /> j� 304 E. Weber, Third Floor, Stockton , CA., 95202 <br /> (209) 468-3449 JUL 11 2003 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> ,pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ma&5kq ' 0Tpl, San <br /> oaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department- <br /> Assessor's <br /> epartment -Jt / <br /> C f I .h� p � ' �� Assessors / 50go 1 9 <br /> FELL Location 16t 615, <br /> `1 �7, �i I �I _�_ 1• C) Cross Street e /S; r I City ;SC 'O ,M Z'ip _Parcel# �] <br /> ROPERTY Owner v, Cl.t� SC� 1' �Lt•- I Address� l)I S • tl St City � 1�1�_Zip, Phone# qj 3 / <br /> f :57 Contractor A �Sl rr Address Cltyr-!s zlp�J_�Lic# Phone# 20(-M' ivJ ",�r7G�/b <br /> onsuitant / Sub Cntr Address `�� S�G�A,�Cifyr f�2LMoU0 Phone# <br /> ;IS Coordinates: X my. Township 114 V O4(RN Range k 6,c } Section S uxST <br /> IORKSO BE PERFORMED: <br /> NEW WELL / BORING CPT, GEOPROBE, HYDROPUNCH; HAND-AUGER, OTHER' 17 DESTRUCTIO choose <br /> ( ) ( type below) <br /> SOIL BO RN 'S OVER-BORE <br /> [] WELL # � � _11 0 PRESSURE GROUT <br /> 7ther; Grout cations: •t la�/`(d1 CC' 0 Ll <br /> :OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGOLLOW STEM DIA. OF BOREHOLE 4,) &' MULTIPLE CASINGS? u MULTI-LEVEL? R WEI I CASING DIA <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING n STEEL D PVC BOTHER: <br /> VAPOR n MUD ROTARY DEPTH OF GROUT SEAL F," i I __ TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> AIR SPARGE / Ozone p PUSH POINT GROUT SEAL PUMPED: p Yes * No (NOTCE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER I, GROUT SPECIFICATIONS: ion I 1 J C &V Q, ' <br /> OTHER:�OTHER o iG[� 4PPROX. BORING DEPTH \ 4t;70 1'JS3, p BOLTED TRAFFIC BOX or O STOVEPIPE <br /> CONDUCTOR CASING PROPOSED? ( if YES, list specifications here)-. <br /> :OMMENTS: <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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordi—n nnnccesI Rules and Regulations, and all applicable California State Laws. <br /> igned x �,� ��, � —Tiflefompany r I SS] <br /> rint Name �pgxla Y \ Date <br /> DEPARTMENT USE ONLY <br /> ;ITE MAP IN UNIT IV FILE, ADDRESS : <br /> VORK PLAN DATED: <br /> pplication Accepted By - Date Issued <br /> trout Inspection By Date nal Inspection By Date <br /> lestruction Inspection By - Date <br /> :OMMENTS / CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PECODES FEEINFO AMOUNTREMTTTED CHECK # 'D Y DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 06 1 - <br /> 57 WC_4AIVER_ C-57 Letter of Author izatf ' 'to sign permit_. Encroa Ment doc_ 8/29/02 <br />