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WELL P&IT APPLICATION FOR:0 SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 - <br /> NON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> plication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compllance with San <br /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> StU1��MAtitnl CAT40"( CfwuTA,4- Assessors <br /> ?LL Location f1ypu4tAtV t_AIQ Cross Street I�A21.y.�G City S�ticTa� Zip <br /> 75Y Parcel# 12S'3j,'3! <br /> py n.i 'CAT14oc.tc 56"oP f • � L CISTY ! tp9s�r Phone# '1/l <br /> P� LOZ <br /> :OPERTY Owner of Address� ' <br /> /O7 2bf-7 <br /> srconbacoorMliLuELI 11¢lcuGn(G Address Sabo 5. Wk/Y AU/ Cltny-k 4ls,0 6 ur�Phone#gL (o3/-3S$3 <br /> >nsultaM/Sub ConhadorLCZ�r -_Address '93-7 'S• Ao I20'4D_city Lic#W277 Phone# <br /> S Coordinates:X ,Y ,Township Range Section <br /> ARK TO BE PERFORMED: <br /> NEW W BE <br /> / -1CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION(choose type below) <br /> n SOIL BORING# 0 OVER-BORE <br /> a W ELL# 0 PRESSURE GROUT <br /> firer: Grout Specifications: <br /> DMMENTS: <br /> 'PE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XIOLLOW STEM DIA.OF BOREHOLE" MULTIPLE CASINGS?a YES 1]NO WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS '_ TYPE OF CASING: a STEEL 1]PVC a OTHER: ✓✓✓ <br /> VAPOR R MUD ROTARY DEPTH OF GROUT SEAL Ta tPL TREMIE TYPE TO BE USED: []AUGERS g,HOSE <br /> AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: )(Yes [I No (NOTE:/MAXIMUM FREE-FALL DEPTH/ IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: L•Adp -rl/& L ZL <br /> OTHER: fl OTHER APPROX.BORING DEPTHtZ <br /> r ID BOLTE TRAFFIC BOX or 0 STOVE PIPE <br /> a, CONDUCTOR CASING^PRn (if-YES,list specifications here): <br /> -OMMENTS:2 �I- `6b+4AL" To .4-40r f� r�Y121AANJ 11j&Z14 <br /> '(�"tz( T (m&( <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 /> iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> auntyfinance�( 'le and Regulations, and all applicable California State Laawws. / <br /> gnedx l� <br /> Tide/Company - 6f WAD ��1Er�Alyt�l�t.�.f.NTAt. <br /> int NameData <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> 'ORK PLAN DATED: q I A <br /> y/ 7 <br /> )plication Accepted By Date Issued QJ1112 1 2'��'"' Area <br /> -out Inspection By V I rl Date./- Final Inspection By Date <br /> :struction Inspection By Date <br /> 3MMENTS I CONDITIONS: - <br /> >CCOUNTING ONLY: AID# cera <br /> IE CODES FEE INFO AMOUNT REMITTED CHECK# BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> (0 zea strn 30 <br /> '-57_ WC--WAIVER— C-57 Letter of Authaii i to sig permit_Encroachment doc_ 1/25/02 <br />