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WFr L PERMIT APPLICATION CORM SITE <br /> �. .i <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 <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 ID7 Sbj,iso. .)!�F Cross Street 1 P& S4—. City Stx�" Zip Parcel# Lrz065 <br /> PROPERTY Owner_Ntj Fz eR -- Address Pru 3c*3S- City SIX111 Zip Phone#AL4134U <br /> C-57 Contractor_VAW [>d64 -dxff t0. AdA,dresl1s�$on 411E City�_ZipRS641 Lic#7?A Sat/Phone#ril6'X77-¢(p(t <br /> Consultant/Sub Contractor 6COur vl �RfFh IGWAt Address 1114 W�w:m S&rrnk Cityl-C�r� Lic# Phone#-f9f-iff <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 'DESTRUCTION(choose type below) <br /> 0 SOIL BORING# `,Q'OVER-BORE <br /> vWFLL# IKAL,3 L3 _ O PRESSURE GROUT <br /> 'Other. T Grout Specifications: ' <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS: SCC Ct4+wet e[➢. .LI tog <br /> ?TONITORING 0 HOLLOW STEM DIA.OF BGREHOLE " MULTIPLE CASINGS?0 YES ONO W ELL CASING DIA:_ <br /> //0--EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL Q PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7S ; TREMIE TYPE TO BE USED: GAUGERS 13�iOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER-_O OTHER APPROX.BORING DEPTH 75 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 Ord' anc , Iles and Regulations, and all applicable California State Laws. p <br /> Signedx LL++���� TT 4Title/Company erelD�'tS�'`4my-A4 ?,B r6 <br /> Print Name_ Deno A.r C-, / Date_ Il 2:7�Oi <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> s <br /> K CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> :550 -Z It 60-`1 $&0-vo 0 )21y5 003232q <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 1/25/02 <br />