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RECE� 1V��[TELLWRMIT APPLICATION FORT SITE <br /> MAY 0 7 2004SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRUNMENTHEALTH304ENVIRONMENTAL <br /> hird Floor, Stockton, CA., 95 OSION Y) UNIT IV <br /> PERMIT/SERVICES <br /> (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 Public Health Services,Environmental Health Division. <br /> WELL Location ZS tJ-�/E3�-��.1� (-,v,�t_a„J r• <br /> Assessor's <br /> Cross Street City ST'OCk-7-c� Zip 957--:s Parcel# 13 _ 260-1s <br /> PROPERTY Owner 5-�LL'7n.J al"NA Address ZZ L.W t'�S�A+0 CitySl c.l-ro.•j Zi 9Sa, w9 93 <br /> P Phone#� 7-STf1) <br /> C-57 Contractor Address Ciry Zip Lic# Phone# <br /> Consultant/Sub Contractor SECo.L Address Sol rJ k-t�5ocd"�"/�JOity �o.MLic# Phone#�9rd��I^OyOs) <br /> GIS Coordinates:X ,Y ,Township I N Range 6 1. Section (C­_,� <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BO <br /> L/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION(choose type below) <br /> SOIL BORING# [I OVER-BORE <br /> WELL#_MW 2/M4�— yam <br /> 'Other. PRESSURE GROUT <br /> COMMENTS: Grout Specifications: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING o HOLLOW STEM DIA.OF BOREHOLE g` r MULTIPLE CASINGS?o YES '8 NO WELL CASING DIA: 2 `/ <br /> Q EXTRACTION *AIR HAMMERIDRIVEN CASING THICKNESS SCr.., yr7 TYPE OF CASING: U STEEL )f PVC 11 OTHER: <br /> VAPOR G MUD ROTARY DEPTH OF GROUT SEAL YC" TREMIE TYPE TO BE USED: []AUGERS ;@ HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ,aYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> ]SOIL BORING aHAND AUGER GROUT SPECIFICATIONS: �'ia'I Ct•vr.,.� <br /> ]OTHER: n OTHER APPROX.BORING DEPTH `�r ACBOLTED TRAFFIC BOX or Q STOVE PIPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED? ' 01 (if YES,list specifications here): <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 Laws. <br /> lltla/Company_PR�3'G c-T Cj rTD wSr ST J S C�d� <br /> 'ft Name "T+Vr AS Y. Date A/^-- , <br /> (- rsZ013Y <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS: <br /> /ORK PLAN DATED: <br /> optication Accepted By. ✓ Date Issued �Date <br /> Arearout Inspection By Date Final Inspection By <br /> astructlon Inspection By Date <br /> OMMENTS/CONDMONS: <br /> 4OCOUNTING ONLY: AID# <br /> cerw <br /> 'E CODES FEE INFO AMOUNT REMITTED CHECK If jREC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> :jj � o� $ �0 2 ? � to d SR# t 3,5 <br /> 57_ WC WAIVER_ C-57 Letter of Autho .Zat�R o sign permit_Encroachment doc_ 9/27/00 <br /> e <br />