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����0 WEA PERMIT APPLICATION FOK - SITE <br /> ��� SAN JOAQUIN COUNTY MITIGATION <br /> 1*1 ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> JV NEA�\N 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> ENS (209) 468-3449 <br /> ENV\FtO��SER�ICES <br /> �r,,��((��,,11,�\ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is tfdrAB11 made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Cpunty <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DIe,p9nment. 7/e7� <br /> WELL Lo tion 216 W• Cross Sheet V Wyy! zi,a Parcew <br /> PROPERTY Owner-H �t'iY� L}A'( s qI city Uzi& . Ii�pI-5-k� hone# Z�) <br /> C•57 Contractor k)45$ - A �Address3 - l l7.r Z`iH 4G Z FN—Z-yd#"l7 V!� <br /> /n� j) ,, n Phone# <br /> Consultant/Sub Contractor 46-6 Address 37 SI CW a city S- Plwne#,�E' C(,67l40(0 <br /> GIS Coordinates:X Y ,Township Range Section <br /> OW RK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION(choose type below) <br /> Q SOL BORING# a OVER-BORE <br /> ELL# UPRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTAL TION E CONSTRUCTION SPECIFICATIONS PAC, <br /> � <br /> ONITORWG OLLOW STEM DIA.OF BOREHOLE /rt 14ULTIPLE CASINGS?U YES Y"' WELL CASING DIA-Z K 1 <br /> U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL,VC U OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GRoLrr SEAL /D F&BT TREMIE TYPE TO BE USED: }'AUGERS a HOSE Q <br /> U AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: U Yes�Xw( OTE- IMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING U HAND AUGER GROUT SPECIFICATIONS: AY4{'(cr,, <br /> U OTHER: fl OTHER APP ROX BORING DEPTH 1. r'e Th BOLTED TRAFFIC BOX or TOVE PIPE <br /> F_,, �, ,.,r,' <br /> CONDUCTOR <br /> CASING PROPOSED? (ifJyES,list specifications here): <br /> 'COMMENTS: Mal',T ` L1 4' LSM l /Zwocf7 r O J'v4rly. 11/SL( <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 I have prepared this application and that the work will be done in acc rdance with San Joaquin County Ordinances, <br /> Rules and Re Mations,and all applicable California State Laws. <br /> /.,�.11 <br /> Signed x M/41-1 , <br /> 'I i Title/Company Gam` <br /> 4,41 <br /> Pnnt Name !'V)/41 A ' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,APDRSs: 11216 <br /> WORK PLAN DATED: I — R('� at In, " I S o I <br /> Application Accepted By l Date Issued -. Area <br /> Grout Inspeclicn By �k: -' Date 6 07- <br /> Final Inspection By z- Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> a�ol 1 1 $'�;q .0a I I (,t,C '4/402 sR# 30gaS <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />