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\V/ ; WELL M � RM1T APPLICATION FOt �,vl SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> JUN 19 Z003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONIUIEIV I HEALTH 304 E. Weber, Third Floor, Stockton , CA., 95202 <br /> PERMIT/SERVICES (209) 468 -3449 <br /> 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 /> Joaqq,u, in County Develo ment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Cj+q Ot Stot Heq ty, rivihisaF• wA7 SOWN FL PufROn Si • Assessor's QQ <br /> WELL Location . vrsnr "ynr0—irreanfTrrr Cross Street Tv . C City 5 /ocri Ta /1 Zip 95206 Parcel# �� <br /> destrigALR 4+ OF 31 7 S, RL - 001400►- ory aSt, P <br /> PROPS WVW'ner, r Addr�ss ityS % K 70r�,z 9S!? O Pho <br /> / N o - " v ' 31e3Z O;EL C //'C/t2 84ovcNa 9S7y2, <br /> C-57 Contractor Conan £ Drrllt� a Address "�` DCiry CoROp�gzip Lic#7/ 751QPhone#_(c" 63 /169 <br /> Consultant ] Sub Cnlr r G . F . Addressb57 S )4AW City S7R (r0t1Lic;# (O`r3QZ2 7 phonekZ.oO yb 7460 b <br /> GIS Coordinates: X Y , Township Range Section <br /> YJ�CRK TO BE PERFORMED: <br /> NEW WELL / BORING ( QPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') Q DESTRUCTION (choose type below) <br /> Q SOIL BORING # Q OVER-BORE <br /> WELL # M W "/ O Mew/ )- f p Q P(ZESSURE GROUT <br /> "Other: Grout Specifications: 1 c% 8 -T/4f%L7 �Y� E. `"fr <br /> COMMENTS SFS 19ppR4QWj) wBRK P16,1 Are.0 RP&L Q33 ? boa <br /> TYPE OF WELL INSTALLATION TWE CONSTRUCTION SPECIFICATIONS <br /> •1ONITORING VOLLOW STEM DIA. OF BOREHOLE 'Dr/ MULTIPLE CASINGS?MULTI-LEVEL? a WELL CASING DIA: t9 <br /> XTRACTION - Q AIR HAMMER/DRIVEN CASING THICKNESS 3ZNA4 Qy IF TYPE OF CASING: Q STEEL Q PVC A OTHER: TF. nnJ <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL R5 f-T. TREMIE TYPE TO BE USED: Q AUGERS `,NOSE <br /> Q AIR SPARGE / Ozone Q PUSH POINT GROUT SEAL PUMPED: Ayes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 9HAND AUGER GROUT SPECIFICATIONS: PoRTlgrjD . Ty -t,LPE " � <br /> Q OTHER: fl OTHER APPROX. BORING DEPTH—/j0l9 FT . OLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AJO ( 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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Reulations, and all applicable California State Laws. <br /> Signed '7 C,14, <br /> Tttle/Company Pt% Lr Goa/o,051 <br /> Print Name / / w10N / v Cv � ,I _14A Date-0 (Of I810J - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 3147 S, El D or a d o. <br /> WORK PLAN DATED :, / p rl � 97 .DZ 002 <br /> Application Accepted By V I C.'(-D ri to M C l'g Nth t Date Issued AU 05+ Jr, 2003 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS / CONDITIONS: 0 7 <br /> ACCOUNTING ONLY: AID# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT I SERVICE REQUEST # INVOICE <br /> 3581 8q. 06 89400 00340of <br /> C-57_ WC.-WAIVER. C-57 Letter of Authorization to sign permit_ Encroachment doc_, 8/29/02 <br />