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°R[CEW)MEELL PERMIT APPLICATION FORM <br /> RM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> (ri�1i< 3 2005ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> ENVIRONMENT HEAW4 E. Weiler, Third Floor, Stockton, CA, 95202 <br /> PERMIT/SERVICES (209) 468.3449 <br /> NON­REFUNDARLE PERMR EXPIItE51 YEAR FROM DATE I=92 <br /> Application is hereby made to Sen 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 T1tie,Chapter 9-1115.3 and the Standards or San Joaquin County Environmental Health Deparbnent. <br /> Assessor's <br /> WELL Locstion�7.0 E, Pi n/3 Sire.e,T Cross Street CI U FF City Lo O r' Ziy i.; `/O PArceliln<)9 - GqO-30 <br /> PROPERTY OwnerpgtnS¢rT SCbag T Address ty !o�Zip ' a_Phone#Z21„364^7e <br /> C-57 Contract",!q Ao Ori Ili nrr�AddresaL32 0W .c C,r. Cly,��C ZipgV% lc#7)7S)o Pwrww916 -638-116? <br /> Consuitantf r R-W eiyVi•�LLa Addrass9714PAMk7tgt CityE)A .w Phonefi4)b'7/A/-3o7S <br /> GIS Coordinates:X Y 'LL 1 q Q ,Tovmship Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL!BORING(CPT,GEOPROBE,HYDRQPUNCH,HAND-AUGER,OTHER-) 11 DESTRUCTION(choose type helow) <br /> )jtOIL BORING B I A nln' :2, 0 OVER-BORE <br /> LL# 0 PRESSURE GROUT <br /> "Other Grout Specifications: <br /> COMMENTS: on)Fi r A+orY of C_ 50rin/aA <br /> TYPE OF WELL iNSTAL,"_1 N TYPE CONS-1 t1CTION SPECIFICATIONS <br /> p MONITORING )(HOLLOW STEM OIA.OF BOREHOLE // MULTIPLE CASINGS?0 YES PQ WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER)DRIVEN CASING THICKNESS TYPE OF CASING: I]STFEL n PVC 0 OTHER: <br /> 11 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS C HOSE <br /> 0 AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: B Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: <br /> a OTHER._j]OTHER APPROX.BORING DEPTH 13 r- 1 S 0 BOLTED TRAFFIC BOX or l STOVE PIPE <br /> CONDUCTOR CASING PROPOSEO? (K YES,est specifications here): <br /> -COMMENTS: C_-� L RhIT 7�1✓Yr ) i�fVy <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 tions In accordance with San Joaquin <br /> County O�ce Rules and R la ' ns, and all applicable Calitonniiaa State Laws. <br /> Signed ) t��// � Titfe/Company /pU�rp I (;r1n)Q,� - "NC ENyrrn.LLC. <br /> Print Name T2-)CJJO N ) O1SOA/ pa�� 3 ^ 4/- a5 <br /> D PARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED':I '/ <br /> Application Accepted By ia !A� Dafe Issued os Area; <br /> Grout Inspection By Date rinal Inspection By pate <br /> Destruction inspection By _ Date <br /> COMMENTS/CONORIONS: Z �-:VI L- RORJA)AA 1:'OR_ 04�uM F:/Vf /(-(v6✓, LC ST- - f S A, <br /> ACCOUNTING ONLY: AID# <br /> FECOOES FEEINFO AMOUNTRBMnTECH CHECKY RECD BY DATE PERMIT/3ERWCEREQUlSTa INVOICE <br /> o �- 4" .�O os✓ 00 ql y3Y <br /> C-57 WC___-WAIVER^ C-57 Letter of Authorization to sign permit_Encroachment dor_ : 1/25/02 <br />