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SITE MITIGATION UNIT IV <br /> o yWELL PERMIT APPLiCkr N FORM <br /> i C E�V E F0SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) Gg� <br /> 2005 304 E. Weber, Third Floor, Stockton, CA., 95202 3 <br /> Ef4Vj'=,'(:vy1ENT HEALTH (209) 468-3"9 !2 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �p <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 vlt San Joaquin <br /> County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County EnvtronmenU Health Department. <br /> Assesso <br /> WELL Location( o • Ll V[Ma[I Cross Street Cl,AaSDi City D t Zip Parcell# -- 1 <br /> PROPERTY OwnerVjWD%Q I Vt-,E @912pQ5Address6,3g j , LDCr-CE�,2-D 4/Cify LOV I Zip 5? Phone#20 /Z <br /> I C.TContractnr� IL-1 AddressZ3�5-Wi6WA—M- co, Zip�c# 57 7,Zt �6s 87/2 <br /> CortsultaM/Sub Cntrt'2awl L.L.- Address yup _Licdk�_Phonef.11S6-231!2 <br /> t <br /> 018 Coordinates:X 38t, <br /> G 22 /7 Y j 7-1 d 1 S' 0 Township Range Section <br /> WORK TO BE PERFORMED: _ <br /> 0 NEW WELL!BORING (CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER`) UCTION (choose type below <br /> 0 SOIL BORING# OV R BORE. DIAMETER l <br /> Q WELL# U p PRESSURE GROUT <br /> O'Othe c� rI GROUT SPECIFICATIONS <br /> COMMENTS:_ ?C J S IT -1 10U[�f�- 9 K U t PL©11Ky� I <br /> I <br /> OF WELL INSTALLATION TYPE CONSTRUCTION SPEC FI A ONS <br /> MONITORING 0 HOLLOW STEM DIA.OF I30REHOLE 0 MULTIPLE CASINGS [[MULTI-LEVEL W CASING DIA: <br /> II EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: STEEL VEC (]OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 ANGERS a HOSE <br /> 0 AIR SPARGE/OZONE (I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: OTHER APPROX.BORING DEPTH _ _ g BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR I PROPOSED (if YES,list specifications in comment section) <br /> : rZ_ <br /> COMMEN �C LE- 4 <br /> NOTE: OFFSITE BORINGS REQUIRE Acd ESS 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 County <br /> Ordinances ules gulati s, and all applicable California State Laws. <br /> Signed x Title/Company 1 r <br /> orint Name t (d_� �f �� � (�lP_�� , Date �— 17 d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> [!YORK PLAN DATED: 9-57iAlx). <br /> 4pplicationAccepted By Date Issued bf�� R _ Area _ <br /> 3rout Inspection ByN Date G Final Inspection By Date <br /> 3esf�on Inspection By Y ate b' 0 S <br /> :OMM ENTS/CONDITIONS:,4 w �' t%r�-S� G�IJ� �* L•O•p ,nM Nt�,Y- ,� r ct& 9S3 <br /> ACCOUNTING ONLY: I AID# V FA <br /> PE CODES FEE INFO I AMOUNT REMITTED I CHECK# I REC'D BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 6027 141 6012S1 /00,7 1 /-,� 1&4$ of SR# 46 q_8Fb <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />