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REM DWELL 1RMIT APPLICATION FC _M SITEIVE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> IV <br /> AUG 2 9 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> WELL Location( -C ) Iii tL( a�ter S�1 Cross Street \j �I , City �oC�i Zip�� a Parcel#6 q/—1 1G - �7 <br /> PROPERTY Owner LcL l re I Y" fit) LSU.address S(i� i�Y OS5 City S1"hi-k1 � zip �i�Phone# ( �_ <br /> C 57 Contractor (51 Address ��7 �I�c �J CitySfin_ M Zip jdlSLic#-6(, po 7 Phone# 'y(�71U�h <br /> Consultant/Sub Cntr - _ _ Address City` Lic#( be a-)Phone# (,26c1)q67 1 e-Z' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> �j NEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL#_ 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I. I .,'MULTIPLE CASINGS?0 MULTI-LEVEL? q WELL CASING DIA:___ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL tL li C , �TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: p Yes` XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: C OiAl -\A <br /> 0``OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and/Regulations, and all applicable California State Laws. <br /> Signed x_ �TI(i�_ Title/Company <br /> Print Name )�� l(,� �>L Date <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE, AD RESS: <br /> WORK PLAN DATED: // <br /> Application Accepted By Date Issuedt!t / Area / Y <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection B Dat <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />