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• WEL` PERMIT APPLICATIO"ff <br /> '' <br /> JyEDDSITE MITIGATION <br /> MIT GA <br /> SAN JOAQUIN COUNTY UNIT A. <br /> ENVIRONMENTAL HEALTH DEPARTMENT QTP)2 I 2002 <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENVIRONMEN T HEALTH <br /> A9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D 'I$'S jjC ERVIC :ES <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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location C i Assessors <br /> 5� J� Un�., Cross Street �r��,,_ Ci��/� Zipparoet# <br /> PROPERTY Owner y I���.,, y J ��n�Address 1 �`r7Y�t ily L�BL zip�4? Phone# J r� e i <br /> C-57 Contractor h)b TN{'L-'f{ — Addor-ess 4Ll City. '�_zip�#5�"one# //6f?-O !� <br /> Consultant!Sub Contractor 19 \�C Address Phone# 467/M(o <br /> y <br /> GIS Coordinates:X Y Township Range Section <br /> W9EK TO BE PERFORMED: <br /> EW WELL/BORING(CPT,GE"OPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 PRESSURE GROUT <br /> "Other: Grout Specifications: <br /> COMMENTS: k <br /> I <br /> TYPE OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING �IOLLOW STEM DIA,OF BOREHOLE ,(,t4MULTIPLE CASINGS?0 YES 0 NO WELL CASING DIA:— <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL VCOTHER: <br /> ;,. <br /> VAPOR 0 MUD ROTARY DEPTH CF GROUT SEAL 16 P6e7— TREMIE TYPE TO BE USED: 19' 11UGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes �01A (NOTE: N}QrX <br /> 0 �� <br /> IMUM FREE-FALL DEPTH 1S 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ' <br /> OTHER: ❑OTHER APPROX BORING DEPTH '7"//!5 f r:87 0 BOLTED TRAFFiC-BOX or STOVE PIPE F <br /> CONDUCTOR CASING PROPOSED? if YES,fist specif ions here <br /> 'COMMENTS: PROPOSED? ( <br /> ) <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 Joaiquin County Ordinances, <br /> Rules and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company 6 F <br /> .}j <br /> Print Name r^jltLT>� /'�)e­' Date o2 a <br /> DEPARTMENTUSEONLY r <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: &tom <br /> WORK PLAN DATED: C <br /> Application Accepted By �L° Date Issued a Area 1:, f -)-- <br /> Grout Inspection By ` "�/Z.C� Date I c IJ-2—Final Inspection By Date 3 ! d-2— <br /> Destruction <br /> Destruction Inspectian By Date - I <br /> COMMENTS[CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE; PERMIT/SERVICE REQUEST# INVOICE <br /> SR# n 711 3 <br /> C-57 WC=WATVEI2� C-57 Letter of Authorization to sign permit_Encroachment dac_ 1/25/02 <br /> k <br /> I Jill!! ► <br />