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ORIGINAL <br /> o Epi EGWELL ERMIT APPLICATION FO", SITE <br /> ��� SAN JOAQUIN COUNTY MITIGATION <br /> MAR 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) j <br /> 3 1 UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> EN�IRUNMENj <br /> COS , u <br /> PERMITISERICES C15_1 1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D <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. - I <br /> Assessors <br /> WELL Location IJW CDR-,JEIL Cross Street City 5T'DC,t­rpr4 Zip 9SZo9' Parcel# <br /> PROPERTY Owner (iLT`f JF Sr-D c..K.. Address 544 eJ. EL Do9ADo Si. City S iarx 'D J Zip")SZJ2- Phone# Z05-'S'3j X5631 <br /> C-57 Contractor Address 24bS DR• CityS�tn.,�Zip 9S?AC'Lic#517.49 Phone# 2r)a-465--6: riz <br /> Consultant/Sub CntrletA_tjjF£ipE;Rr1.AL.. Address_2.y LQ E. ^-,,'I(tn.F CitySV>f_ JLic# Phone# 2di.-4.4�6-134s <br /> GIS Coordinates:X ,Y ,Township L t, Range 6 r_ Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> ll SOIL BORING# H OVER-BORE. DIAMETER <br /> KWELL#C,S-I-jarot-t-60r US-1-40 (1 DOX10 C'- 3 wEwI HPRESSURE GROUT <br /> II`Other 6o(ty-!fn GROUT SPECIFICATIONS <br /> COMMENTS: DIJE o46rtE SPPALC_v.J(-. T7NCaE iPPRc.E PO �at� <br /> INSihu.E-0 ai �F-z­i-A-) Of 30`. 6D`. fit] �1J` DELo„J C�Ro.n...lO W?�TZ-R• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n <br /> G MONITORING •HOLLOW STEM DIA.OF BOREHOLE If MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_I <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS S,tA. 40 TYPE OF CASING: l)STEEL ;(PVC n OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEALZS Sf tb.J t.W TREMIE TYPE TO BE USED: AUGERS 0 HOSE i <br /> )J�AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: gYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> o SOIL BORING p HAND AUGER GROUT SPECIFICATIONS t SAT GE.MF,J-C <br /> H OTHER: _U OTHER APPROX.BORING DEPTH al iSE.-Jw,CO $BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment 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 Ordinance ,Rules and Regula ' ns, and all applicable California State Laws. <br /> Signedx Title/Company SjA'rf Ery/ r0Iz.E�2-- ` IC-L.En 1f-f- DkR=I Wf <br /> Print Name IBJ 1 — Date�`03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: IID N- <br /> WORK PLAN DATED: I-/5—fl3 <br /> Application Accepted By G(Mt-Q� Date Issued ED Area <br /> 0%g <br /> Grout Inspection By. Date _ Final Inspection By Date <br /> Iii <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35oI PILO 6:9 F5 aA 13.3/ SR# 303 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc✓;_ 9/30/02 <br /> ii <br />