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07/19/2002 08: 18 2094683433 r Lr n rLuur< rruc u� <br /> WFL-a— PERMIT APPLICATION FuRM SITE <br /> SAN JOAQUIN COUNTY MITIGATION��-� ����,/]��� <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) Uk �_ <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 1 3 ZOOZ <br /> (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LNVAUNIMENT HEALTH <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',� t rTAfT t\+_rES <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> WELL Location 7 jVK,rY Cross StreetCity��C3�kCCni ZIpAS:)C�' Parcel* 1�,1-0�0-O-_3 <br /> PROPERTY Owner ST Sk-�L�c_E� Address _Z:1n 4I Iy,,.y 1!P City _a`TO.� Zip':1SX)6 Phone#(:?OqN 9L13- 6r2 <br /> C-57 Address -�`�41 Vjt.� Ciry a4r5c Zipa�r`.91 <br /> Consultant/Sub Contmctor URS Address�7 QZ Sr Ling Phon . 516 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE rj RM D: <br /> af4EW WEL(/BORIN EOPROBE,HYDP,OPUNCH,HANG-AUGER.OTHER-) p DESTRUCTION(choose type below) <br /> 17 SOIL BORING# a OVER=BORE <br /> 0 WELL 1 p PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITOPING n HOL!OW STEM DIA.OF BOREHOLE_MULTIPLE CASINGS?[]YES RNO WELLCASING DIA:_W) <br /> 0 EXTPAC71ON it AIR HAMMER/DRIVEN CASING THICKNESS Nom_TYPE OF CASING: p STEEL 8 PVC (]OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS )KHOSE <br /> (1 AIR PARGE n PUSH POINT GROUT SEAL PUMPED: No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL PORING f]HAND AUGER GROUT SPECIFICATIONS:_ _t-TA JC <br /> n OTHER: R-6THER Cj"V APPROX.BORING DEPTH IOCY q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? LLD (if YES,list speaficatlons here). <br /> 'COMMENTS: �1�)R�;y�Ff�rC �tiVcS�1'CA�CL)r`J <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 49 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 Orrlina c s RpLes and Regulations, and all applicable California State Laws. <br /> Signed x F L-11 Title/Company <br /> Print Name f.EEt APs« Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �/J <br /> Application Accepted By M-rrc-t' Date Issued <br /> Grout Inspecticn By Date 11/10/07, Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMIONS: <br /> ACCOUNTING ONLY: AID# <br /> cern <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> SRtt OOYZ 9 P(o <br /> C-57 WC,_-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />