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1 I13:4f Ltl74GtlJg3J rII- IH rLuuK I'AfaL 114
<br /> JUN 2 3 2004 WELAERMIT APPLICATION FO M N JOAQUIN COUNTY SITE
<br /> ENVIRONMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION
<br /> PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV
<br /> (209) 468-3449
<br /> NON-REFUNDABLE PERMrr EXPIRES i 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 Joaquin County Environmental Health Department
<br /> WELL Locati. S. j.t ra61t to 94. Cross street_ ur. ClryT,",,,tk C D,!(i_Zip
<br /> pS. Z�� arm el#ors
<br /> PROPERTYOwner Net✓l:d HaIZ L,o- Address. Satraaa.t[ St. City [ / zip 951 y0Phon -7/7/
<br /> C.57Contractor 0't5^ r, Iiia, Address 9.r�'� yu..� /Zot, Cty a [ 2ip /�ss3Lic#�67phone# 182,52irJ -.5800
<br /> Consultant/Sub Cntr 7I4i✓ Address_l59a S./a., a y,StL.ACity�oLtaro(, l.ic# Phone# l'9�SJ6'6'P-/.2o0
<br /> GIS Coordinates X ,Y .Township SIA( Range D E Section Z-Z
<br /> WORK TO BE PERFORMED:
<br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTNER•) n DESTRUCTION (cioosetype below)
<br /> B SOIL BORING# OVER-BORE. DIAMETER
<br /> ELL# OS- i PRESSURE GROUT
<br /> other LPT-A3 SP-1 SP- SP SP-y SP -- S
<br /> COMMENTS: I1 rP-r-23: °� 3� GROUT A,; IICATIONS
<br /> CPT Sor,,.3_�) cP-r }Lv fit, $P^S_,Ozo,,c ��� ' tc
<br /> D OS-I : nb t�'r vat,or. Wsll
<br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ObSor✓n F,'o.. we!(
<br /> ;'q.MONITORING 2)3.IKHOLLOW STEM DIA,OF BOREHOLE_� o MULTIPLE CASINGS 0MULTI-LEVEL WELL CASING Dw-�_
<br /> n EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS S Y'0 TYPE OF CASING: Q STEEL ` 'PVC t]OTHER
<br /> I VAPOR a MUD ROTARY DEPTH OF GROUT SEAL_ 5'17 Pf, TREMIE TYPE TO BE USED: NAUGERS n HOSE
<br /> 1,9 AIR SPARGEI OZONE
<br /> ,LaPUSH POINT(GP or CPT)GROUT SEAL PUMPED:,XYes nNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 302)
<br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS MtAf L o.l g t , rPT c t•Ir..✓
<br /> ltyeL�
<br /> Ir&OTHER: LPT p OTHER APPROX.BORING DEPTH 10 .Pt. $BOLTED TRAFFIC BOX or p STOVE PIPE
<br /> CONDUCTOR CASING PROPOSED— 'V0 (if YES,list specifications in comment section)
<br /> COMMENTS: ePT Bor%1- ^' 1,'h o(i4 b 0 ut. /}ir L .i,.tS ., a ...L a �v Q }. ;/ Sal„ LiP PUC
<br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. i`,al�
<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 with San Joaquin
<br /> County dinaoncresr,/Rules /d77"Re Mations,and all applicable California State Laws,
<br /> ,yss ?yam
<br /> Signed 7LE�- - � Title/Company L� �K-
<br /> PrintName
<br /> 7 -�r►1J L Date r L�� �'
<br /> DEPARTMENT USE ONLY
<br /> SITE MAP IN UNIT IV FILE,ADDRESS=
<br /> WORK PLAN DATED )
<br /> 4pplication Accepted By ML Date Issued �_z--/ OY
<br /> Areadl
<br /> 3roulIns sctlonBY `hL�+ Date ' O 1
<br /> Final Inspection By Date
<br /> Destruction Inspection By U Dale
<br /> :OMMENTS I CONDITIONS: L li'LJ-D
<br /> ACCOUNTINGONLY: AID# FAC#
<br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE
<br /> a -7O JAGo sR# 00
<br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02
<br />
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