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06/0-7/2002 10 55 20 a462::033 FIFTH 0i^ <br /> FAGS 62 <br /> WELL Mr-ERMIT A,f�: L���'._?':rJL',i ���' it SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> • 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> ' (209) 468-3449 mmm <br /> NOfv REFUNDABLE PE4141T GYP°Q5 "_tip^r^ FROM DATE ISSJED <br /> Ap7€icatton is yerf5by made le San.,oaculn County fo a Nrmit to zvnstruc 4,tdror,nstall th(,v ork descrtecs Thts applicancn is made+n compflarce with Sar <br /> JoaQUn Ccul De,efa mant Ti,fe Chapter 9-1115 3 End lhs Standards c '„d� I ,,i c County Environmental Health Department <br /> WELL Location 2 0� ,v W,,L Assessors <br /> ---�—�- 7Y Cros.Street�drr wrrt� Clt,r SGlEr^- Zip_9fzot parc9l* ^Of__;=! <br /> PRCPERTY <br /> Owner_!9-/��'�.� ,address2772.7A/Cd^r-..eA,.W uty/ 40E►cjJr_Zip_g�oo�Phone# X02- 2 3-6&47 <br /> C-57 Contractor e-4�� Address_ . Z mfr�C. City ZI 9�7� GTy� <br /> p_-?etc# 1of�hcne� `l/6-635-'169 <br /> Consultant l Sub <br /> ' Conlractar rr.'o.tyy�,yr Adt[ress/Y33 /L 3/ }}re C,tYP40eA?>Q Lic# Phone#�aZ- <br /> �{ �� � 72 <br /> GIS-Coordinates X `3Y�5 � $? Township Al Range_ �� Sact�$onrp37qe� <br /> 7 <br /> _ <br /> WORK TO BE PE2FORMED <br /> ' ),NEW WELL!BORING(OPT GEOFRCBE,HYDROPLNCH,HANC-AUGER OTHER- <br /> 0 SOIL BORING# ) !7 DESTRUCTION(choose typo below) <br /> WELL ir_1+_t w- 10 v�j�1j L Q OVER-BORE <br /> `Other -- �Grnut Spectlications 11 PRESSURE GROUT <br /> COMMENTS �k•,.�r71-- ; ' <br /> TYPE 0L, IVSTAI_La TION TYPE CONSTRUCTION 9FECfFIGAT___IONS <br /> if NIONITORIN 3 i I HOLLO'N STr=M DIA OF BOREHOLE-/P /f -MULTIPLE CASINGS?`YES []NO 'NELL CASING DIA <br /> ' Q EXTRACTION 'AIL'HAMMER DRIVEN CASING THICKNESS 0 /" TYPE OF CASING Q STEEL II<PVC Il OTHER <br /> 0 VAPOR L; J ROTARt AEPnn OF GROUT SEAL 3Z`- _ TREMIE TYPE TO BE USED J AUGERS t I HOSE <br /> RIR SPARGE4 PUSH POINT GROUT SEAL PUMPED 0 Yes it No (NOTE' MAXIMUM FRLEE-FALL. DEPTH IS 30') <br /> ' 0 Q OTHER A �Y IL EORING a HAND AU ER GROU-SPECIRCATICN5 ¢t�G'G+��rr.� ���dg <br /> HER aPRF(jR r. j=r1- - -_r;' bT9CL IEDTRAFFIC BOX or p STOVE PIPE <br /> 'COMMENTS <br /> �,� CONDUCTOR C•"0 NC nP^ohCED� �r t Y_S,list specifications here)_ <br /> C�KP�--�� ���, C <br /> ' — <br /> L.U%NGS REQUIRE ACCtSS OR EN'- 164UALWivl N) PERMITS. <br /> CALF.!-,E GZ T IV rOR 48 WORKING HOURS IN AD %-NCE FOR Al-I­REQU[RED INSPECTIONS <br /> I hereby certify that I have prepared this application and that thO 00i k will be clone In accordance with San Joaquin <br /> County Ordina <br /> nces <br /> , 'Rules and Regulations,and all applicable California Share L2-,s _ <br /> ' Signed x tib+ _ _ <br /> ,,,J l�aa T�tlelCormpan} <br /> Prnt Name_,,,_-&t`-e t r - "..'C U Date <br /> ^� 1 r-PARTMENT USE ONLY <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED W" t/ '•h I <br /> ' Application Accepted By_ ' _ Date Issued Z Ii —o Z Area dL <br /> Grout Inspection By _ _ -_ _ _ -,- Oate Final Inspection By <br /> _ C3t9 <br /> Destruction Inspection By <br /> COMMENTS f 177NUITIONS --^_ T •• <br /> ACCOUNTING ONLY , Afu'm <br /> P ODE5 FEE INFO I ��iA(_ll-IT REMI `-7 CHECK9 REC'oBY DATE PERMITfSERVICEREQUESTI� INVOICE <br /> l� Jl,L3a i 2'ZSK3Z R 007-1049j <br /> ' G-57�, W'�_ ►--+lv 9:vt=R�-._ C-57 Letter of Authcrizatlon to sign perrntt Encroachment doc 1/25/02 <br />