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WEAERMIT APPLICATION AM SITE <br /> MITIGATION <br /> REC ENED SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> JAN 2 6 2004 304 E. Weber, Third Floor, Stockton, CA., 95202 ['� D <br /> (209) 468-3449 ` �" <br /> tf4VIRUNMENT HEALTH <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 Jo/�a�grruiry County Environmental Health Department.Assessors <br /> L425 l� &Ce� Cross Street city�Zip 4S376 Parcel# )2 08 sa00 <br /> WELL Location p ' I pp'�� <br /> ����� '2J$?'] NII4 Wph, & City Ck�vo Zip qg DPhone# 9_I SI]1$IS <br /> PROPERTY OwnerVbAtl �o+L'NG. Address 1 [A <br /> C-67 Contractor lA�aO C '�- J�'�Z-Lic#IPhoria4jc <br /> ]�(j Address CiryJCb4S�o Zip <br /> I <br /> Consultant/Sub Contractor <br /> B � <br /> Inv. � Address r+Tl —Cityp�`� Lic# Phone#F; 7Z <br /> Y ,Township Range Section <br /> iiia Coordinates:X /;, <br /> WORK TO BE PERFORMED: 0 DESTRUCTION(choose type below) <br /> EW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 OVER-BORE <br /> 0 SOIL BORING# �g 0 PRESSURE GROUT <br /> ELL# <br /> I I �N./at. n X17 <br /> X'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �H HOLLOW STEM DIA.OF BOREHOLE Sir MULTIPLE CASINGS?0 YES YO WELL CASING DIA: 2�7 <br /> U EXTRACTION /0\AIR HAMMER/DRIVEN CASING THICKNESSr}�4.��PE OF CASING: 0 STEEL �PV`CJ.O OTHER: <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O—M TREMIE TYPE TO BE USED: HAUGERS 0 HOSE <br /> U AIR SPARGE U PUSH POINT GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM <br /> fImE (€ALEP�THr`S 3 <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �j% g_e9L}LWk-rrr^" " ani <br /> 11-1 <br /> 0 OTHER:_O <br /> OTHER APPROX.BORING DEPTH �'FO ` BOLTED TRAFFIC BOX or 0 STOVI=PIPE <br /> CONDUCTOR CASING PROPOSED?�Q_(if YES,list specifications here): <br /> "COMMENTS: <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 /> County Ordinan s, Rules an egulations, and all applicable California State Laws. L� - � <br /> s Title/Ccrnpany ` IL'DrF.ul. V . �ti ' <br /> Signedx_,o <br /> c [4i^r.fn _Date Y <br /> Print Name /�?bT DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 4 S Larch Ido a� TY�IGU� CA <br /> WORK PLAN DATED: 2 <br /> r Date Issued >' Area <br /> Application Accepted By �a- ,,,,,,,,,��'"""��'��/ tG Or/$ae r <br /> Grout Inspection By VitOY�� L. rnd_�l'�S'tEl�Datej) 2 2 2ztuSFinal Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS ICONDRIONS: = <br /> r - <br /> ACCOUNTING ONLY: AID# cer�e <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 350 1 94. op 99. od s►z# 00 3 / P7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> 1/25/02 <br />