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PAYMENT WELL ERMIT APPLICATION FL .�M SITE --- <br /> RECEIVED <br /> SAN JOAQUIN COUNTY MITIGATION <br /> go V, 6 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> SAN JOAQUIN COUNTY 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENTAL 209 468-3449 <br /> HEALTH DEPARTMENT <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 Tiiflee,Chapter 9-111/5.3 and the Standards of San Joaquin County Environmental Health Department. <br /> '°( / [ ss Street U KY` 9�Zy3 Assessor's/2 <br /> p <br /> AfELL Location /V � Parcel# ( <br /> 'ROPERTY Owner 1� tkD3 �l" Sh / ��"'� City p g5204one# <br /> .-57 Contractor Address�32 i Qtrbi �""' `Rhone# `t>�7 6 <br /> 1 <br /> :onsuitant/Sub Cntr I t Address 1 City � It Lic# Phone# � <br /> 3IS Coordinates:X Y Township Range Section <br /> VORK TO BE PERFORMED: <br /> EW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �+ DESTRUCTION(choose type below) <br /> ][��OIL BORING# o OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> Other: Grout Specifications: <br /> 'OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I✓A <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLE— "1 ULTIPLE CASINGS?0 MULTI-LEVEL?Ia WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /1/)4- TYPE OF CASING: []STEEL a PVC 0 OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL-:;V TREMIE TYPE TO BE USED: *UGERS j]HOSE <br /> AIR SPARGE/Ozone 'PUSH POINT GROUT SEAL PUMPED: a Yes JVo/( OTE: AXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: �W T'�Q✓t <br /> OTHER R OTHER APPROX.BORING DEPTH 3 — BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR ASING PROPOSED?�/l,4— (if YES,list specifications here): <br /> COMMENTS: <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations, and all applicable California State LawssI. <br /> igned x r!/,V ayt-�'pr�/ -- Titie/Compaa <br /> rint Name Date l <br /> DEPARTMENT USE ONLY <br /> ;ITE MAP IN UNIT IV FILE, ADDRESS: 17&(::) iV ` lO <br /> VORK PLAN DATED: t 'LAJ (.5 <br /> l %1 uR•r�l oZJ)}j — Gl>�I� <br /> pplication Accepted By Date Issued Area '977 <br /> ,rout Inspection By Date r'Z D Final Inspection By � Date [ /� <br /> )estruction Inspection By Date <br /> :OMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 sot 89 9 i 9 747 r <br /> :-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br /> AR <br />