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DECEED <br /> u t ty <br /> ,r�oa•,q• UN p 4 [004 y SAN JOAQUIN COUNTY SITE <br /> -, ENVIRONMEfV k*Ak jNMENTAL HEALTH DEPARTMENT MITIGATION <br /> PERMIT/*J\## ftUeber Avenue, 3 d Floor, Stockton,CA 95202-2708 <br /> ' <br /> (209)468-3449•Fax:(209)468-3433• Web:www.co.san-joaquin.ca.us/ehd UNIT IV <br /> C/a agN�P <br /> WELL PERMIT APPLICATION FORM <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 /> fii�AtA*I! 27S 411CSr� 47,CJ,fON Aub Assessor <br /> ilYEtt Location Cross Street L,+/Gy�ni Ci SrotKroN <br /> ty Zip 95206 Parcells <br /> PROPERTY Owner Address 375 14 ,02V4rvAl City C7e'eia1rUA/ Zip Z06 Phon?'ir24?2gy3-�7 <br /> C-57 Contractor 1 (`(1 .k � Address'-Ila-"1'), CiiPrl� . 21751 # - <br /> ((0� tic# e <br /> ,Z/avcNo <br /> Consultant/Sub Cntr. A4 r? £m lil/G Address ?6V !lT/G4 Ay6 Cit -',1^'P*A4 / <br /> � yam" Lic# Phonerr<�0W 9'76-0I2D <br /> • Gv /730 <br /> GIS Coordinates:X j/,�o^�/�S 6c/i�s,y�6.3�/�1 Township Range Section <br /> 567 j7 <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# 0 OVER-BORE-DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other: 7 Soil, 4qG121al345 Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS .00 Gr cu's IV 66 WSTAu,�•y <br /> 0 MONITORING ,HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 4 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE )�pUSH POINT GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,k-50I1-BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: 456'9' AfThGNy--) !-,1e2Z - Pt/M/ /Ze'Z jSi7C,,04"91✓ <br /> l Sv 66-C X1712 .aso G6,725;¢ r,&— ,,,W,obkry eX,,44/q. -9u7Hoe,.7A16 Ci2rL�,.✓rs <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 Ordinances, Rule/snd Regulations, and all applicable California State Laws. <br /> Signed x �?� ��v it Title/Company ret <br /> Print Name Jf1"t6 a x- SCSi% Date <br /> `J DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: _ <br /> WORK PLAN DATED: <br /> Application Accepted By Date IssuedD y Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: /1ifl (MS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SRO L 3 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WELL PERMIT SITE <br /> 8/27/2003 <br />