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WELL I � RMIT APPLICATION FO,. A SITE <br /> l <br /> SAN JOAQUIN COUNTY MITIGATIONUNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 pgnmiLt nsW c or install the work described. This application is made in compliance with San <br /> td <br /> Joaquin County Development Title, Chapter 9-1115.3 a the Standards a a in County Environmental Health Department. <br /> _ 0 ' ,�1 ` t Assesso p <br /> WELL Location 1 , � y�YY'L"r''/i"�!C ee (2 (<- s '� City ljlu/ Zip 2�Jz Parcel# 3 � � 'S�� I <br /> PROPERTY Owner �/� /� L ` ✓��S Address �� f3CX 99/?I p City_S�t Q l7�i Zip %5" VZPZhone# <br /> C-57 Con tractori 'fe t^ ia/"//�I�//r(/f�Addressxt ng77„` 1 /yrr�UWyy��G City4k �dr�{,�ip, )� Z7�7,Lic#6724iVAhon <br /> Consultant / Sub CntrtrA96 x(Yd DCA)tf gddress �J�i ?$k1f4U /Y/ City C �t &kJ1Jc# v 7—Z Phone# 2 � -W&L , <br /> GIS Coordinates: X , Y., Township _ Range Section <br /> WORKTBEAERFCRN P- <br /> )L�EVtWELL CR NG )CPT, GEOPROBE, HYDROPUNCH; HAND-AUGER, OTHER* p DESTRUCTION (choose type below) <br /> SOIL BORING # <® H U OVER-BORE <br /> WELL # o 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? [I MULTI-LEVEL?WELL CASING DIA: 1/ <br /> 1] EXTRACTION 1] AIR HAMMER/DRIVEN CASING THICKNESS S't k4Ji) TYPE OF CASING: 0 STEEL $PVC 0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL.2U - YZ) r TREMIE TYPE TO BE USED: 'jkAUGERS [I HOSE <br /> a AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: Yes e v No (NOTE: MAXIMUM F/REEAFALL DEPTr�H, IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: ❑ OTHER APPROX. BORING DEPTH /,C It) / 'BOLTED TRAFFIC BO)ear a STOVE PIPE <br /> ,. 1 - pp �j <br /> CONDUCTOR CASING PROPOSED?W1A, ( if YES, list specifications here): <br /> 'COMMENTS: a4 lh?Wf/ LJ<J_i ! k 7---TSI 0 fle)le 4� rl! / .1 cy /)a/S' ! <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 accordance with San Joaquin <br /> Count Ordinances, Rules and Regulations, and all applicable California State Laws. ' y// <br /> Signed / - O Title/Company �� ✓) 7� " ' Nmwr <br /> 0 <br /> Print Name ct n & Date / <br /> JDEPART�MENT U/S��E ONLY J/J /n <br /> SITE MAP IN UNIT IV FILE, ADDRESS : / � 6 / " Wx ( " 6, VI) gps (le v u a� � O� <br /> WORK PLAN DATED ' <br /> Application Accepted By '/ V Date Issued JAl OOII <br /> Grout Inspection By ate mal Inspection By DatelA2/' <br /> Destruction Inspection y Date P 4r <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC' Y DATE PERMIT / SERVICE REQUEST # INVOICE - <br /> 5 � 2 0 15 0 <br /> C-57_ WC.-WAIVER. C-57 Letter of Autho ort t si p mit_ Encroachment doc_ 8/29/02 <br />