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iw vur cc,oc au.Yr cv���a,�Y�� r it rn r"�'M rmQ¢ U4 <br /> WELAERMIT APPLICATION F041M SITE <br /> RECOWE10 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JUN 2 3 2004 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> (209) 468.3449 <br /> ENVIRONMENT HEALTH NON-REFUNDABLEPERMIT EXPIRES IYEAR FROM DATE ISSUED <br /> Appllcado�fg'MB;t1�`ttSd 9;an 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 Ttie,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> p Assessors <br /> WELL Location /38 S, 9 f ock fjph S+, Cross Street ( /ewa. /A, City tow; Zip /5) Y I Parcel# 0�7-6yo- l J? <br /> PROPERTY Owner <br /> t Udll�.y TNdNSfrjeS Address Jt�/]' S. 9fiG�c f•ti S�. City L°di Zip Zr Phone# lZo9J j6'P-P'8Pl <br /> C-57 contract (r <br /> or rt,r�3 -FPr-!Uwe Address /L0 /10 i,..e Rn(, City Ma,;,'neZ Zlp 9rSS�ucu e eS 01Phonen 19Z3� j/1-S8� <br /> Consuliantf Sub Cntr I R Z Address �SqO .70 Awa W4Sde.City data.eL tic# Phone# (IIS-) <br /> GIS Coordinates:X ,Y Township S'/v Range eF_ Section <br /> WORK TO BE PERFORMED: <br /> X NEIN WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OYHER•) n DESTRUCTION (choose type below) <br /> n SOIL BORING# 0 OVERBORE. DIAMETER <br /> 0 WELL# n PRESSURE GROUT <br /> K•thher LP r- 24 c tpr B..l.�a GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLS,2 r' 0 MULTIPLE CASINGS 0 MULTI-LEVEL W ELLCASING DIA u/A <br /> U EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS MIA TYPE OF CASING: 0 STEEL 0 PVC n OTHER: IVIA <br /> R VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ;irt boriA5.TREMIE TYPE TO BE USED: U AUGERS R HOSE <br /> a AIR SPARGE/OZONE PUSH USH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING nHAND AUGER GROUT SPECIFICATIONS Dilef tt. t LPr= Z ll. } !/vo/i<.ee c[= ttA.r ,opt <br /> ,'OTHER: J P T n OTHER APPROX.BORING DEPTH 130 ,f t. n BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Alte (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 with San Joaquin <br /> County rdien�an�ces�, Rules d Regulations,and all applicable CaliforniaoState <br /> Signed _Title/Company <br /> PrintName �F�ivts V A-r7 Date 6�zi/� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 4pplication Accepted/Bfy/.-1�1C r Date Issued (O f T Area <br /> 3rout Inspection By.Fd' Date? Z-9ItH'Final Inspection By Date <br /> Destruction Inspection By Date <br /> :;OMMENTS/CONDITIONS: W t <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 106,70j4&-- 1W,740d SR#00 8S 75- <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />