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PERMIT APPLICATION PdRM SITE <br /> SAN JOAQUIN COUNTY <br /> 3IVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> p3QC� '8 <br /> 104 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <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 San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 36 c) Wesf G"04 �-%rye �ross Street) 1001^ dP -CityGr LTZip25�7Parcel# Z32-igC)-01 <br /> PROPERTY Dg1kaS,TA Zi S 2- <br /> Owner -]-lsi2veJ1, �A tr. Address P'0' go)( 1 1 -_City-_ p] Phone# <br /> C a2 Dr`1} n Lc j&ovo <br /> C-57ratsca I ; R Address 3632 On'tiec_ Gi r City CcdoyA Zip`{S742Lic# 51D Phone# 41�638 149 <br /> Consultant/Sub Cntr S is-C.oR- 1:%:-±rn1d-1or4ddress'3'1'7 k%�5 t,-e P,&, City RI­c�ko Lic#GS-LA q 4 8 Phone# C41 t 6�$b�-0400 <br /> Ste- 100 <br /> GIS Coordinates:X 'Y Township_ 2S Range S� Section <br /> WORK TO BE PERFORMED: <br /> $,NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> n SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# tAW-t 'rhrousy' few- /A".4-6D p PRESSURE GROUT <br /> `Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> %MONITORING 'HOLLOW STEM DIA.OF BOREHOLE []MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: Z� <br /> EXTRACTION H AIR HAMMERIDRIVEN CASING THICKNESS SG�TYPE OF CASING: A STEEL )(PVC []OTHER: <br /> la VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED: '$AUGERS a HOSE <br /> a AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes )(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: p OTHER APPROX.BORING DEPTH gym' ,tw b D BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED-Yes (if YES,list specifications in comment section) <br /> COMMENTS: ��!-6(�=}S,I iq hurel.a`e i 0 c�ia ('+e-ei CcnauGi-or GcsSi/moi ion S' is pump¢. <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 Regulations and all applicable California State Laws. <br /> SignedxTitle/Company 2cr Geol iSf SEGo2 �r+�ernq iongl <br /> Print Name i aVF Ga Date ' 12(7103 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a-690 C <br /> WORK PLAN DATED: c6 I-A o 3 <br /> Application Accepted By Date Issued ( Area <br /> Grout Inspection By Date b Final Inspection By Date t7 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3 So 1 S'Wct.00 5.6c60 G4f I 10112J63 SR# 4�;-L S-Z.2 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />