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III/UC/ZOUZ ID:4/ ZU9J4bbd4dd h1hIHI-'LUUH PAGE 04 <br /> WEAERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appllczdon 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,Chapber 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> T ff t� Assessors _ <br /> WELLLocation Jlzq-A�1300 S. $r�,/cra.&fp .� Cross Street T6MArat1( Or, City La�� zip 75--?/o Parcel# <br /> PROPERTYOvmer /�/yLw[d H°�Z {,kG• Address /�a/195, J^h[Y�•,•r�>o YACity tAd Zip S��O P <br /> hona# <br /> C-57 Contractor Gys� //ri1/�n� Address / 19 /Td we 1W, City/ i e2Zp9P`S�3 Lidt �Phoned OO <br /> t 1 <br /> Consultant/Sub Cntr TA - Address 50.h_AC°�rrr:r�)e6ity ,OntarW V� Phone# (°/2S_/6-'0—/�DO <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> SOIL BORING# UOVER.BORE. DIAMETER <br /> U WELL# U PRESSURE GROUT <br /> 13'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ./ <br /> U MONITORING WOLLOW STEM DIA,OF BOREHOL �� a MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA:*114- <br /> 0 EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS ,Jv ZATYPE OF CASING: I]STEEL ii 1-vc n OTHERt <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 70 X-t TREMIE TYPE TO BE USED; U AUGERS U HOSE <br /> U AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 3(Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 'SOIL BORING fl HAND AUGER GROUT SPECIFICATIONS /I/e•31!-� eer,th t <br /> U OTHER: n OTHER APPROX.BORING DEPTH 70 Tf, U BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N a (if YES,list specifications in comment section) <br /> COMMENTS: <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 vV��aJoaquin <br /> County O dinances, Rules a Regulations,and all applicable California State Laws. <br /> signed �� UG TitlelCompany�®"`��°'9TT�/'S`yI�/���' <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS= <br /> WORK PLAN DATED: 7 <br /> 4pplication Accepted By tom` Date Issued ZJ O3 Area_ <br /> 3rout Inspactlon Bye Dale / [t 07 Final Inspection By Date <br /> Destruction Inspection By [)ate <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMI TED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> //;/07 SR# pv322 <br /> C-57_ W(:---WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ 9/30/02 <br />