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WELARMIT APPLICATION FOM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <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 /> 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 <br /> San Joaquin ounty Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> OO 1 Ste— / �, Assessors <br /> VVt:LL Location tl- ZY� _Cross Streel'& 7S Cit Zi q <br /> "��TTT y p <br /> Parcel# /R <br /> PROPE ��— (� '�11 ��jj tw,cc,, s� 7 �/(Y/ <br /> Owner N/�^"v_ Address�ll.r lX I�l i City —ar�t _Zip Phone36pt.� dJOq'�-r�s <br /> C-57 Contractor /A✓_/ Address�oLlJe+—,c71(I/� S7�Sfi City S�EZipJ'Lidi�� Phone�iky/� /J� <br /> Consultant/Sub Cntra Address��Zc�C./yy/ Lr= CityLic# --- Phone#)'7a s <br /> GIS Coordinates:X Y ,Township Range <br /> Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER,OTHER-) LGROUT <br /> TION (choose ty below) <br /> 0 SOIL BORING# -BORE. <br /> DIAMETER <br /> p WELL# SURE GROUT <br /> 0"Other SPECIFICATIONS <br /> COMMENTS: tt rC5 - IP.Sd <br /> re <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> jKMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:.-3 <br /> IA:. y <br /> 3 / <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /. 41D TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ROSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT) GROUT SEAL PUMPED: �T Yes p No <br /> (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') / <br /> �]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment <br /> Section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Re ulations, and all applicable California State Laws. <br /> 3ignedx Title/Company5 -" / <br /> Date <br /> DEPARTMENT USE ONLY <br /> ! <br /> SITE MAP IN UNIT IV FILE,ADDRESS: OC .SO L4yenJ - <br /> WORK PLAN DATED: �( <br /> Application Accepted By Date Issued /S U Area <br /> Grout Inspeetion By Date inal Inspection By Date <br /> Destruction Inspection By DateVr <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID#' <br /> FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* PERMRI SERVICE REQUEST# INVOICE <br /> a,9D (VD 4 f!ff SR# <br /> 37 <br />