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<br />FILE COPY <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />piplication is hereby made to San Joaquin Countyfor a permit to construct and/or install the %fork described. This application is made in compliance vith San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards ofSan Joaquin County Environmental Health Department. <br />Assessor's /K 030. C/2-' <br />NELL Location 2i5 W. Witsiiirl5-1-on 51-yee -I- Cross Street NIP, City Stockton zip q 52C3 Parcel# ?A <br />3 ROPERTY Owner Orwtect StOrale, Address 2-115 lAl• Washl 115-11)n St. City 5iGC11.+DY1 Zip q5 20 3 Phone# 2.0c1 - Lilco - L-1-3 'I I <br />-57 Contractor Fist h enviicn mean_ i Address — CityWilel., n Zip 9525Z Lic# 6536125 Phone# 2.,D9 -111- 3510 <br />Delta-, Sctio Rice Crer le. nc,...A.i. ave,vt vv, <br />:.:onsultant / Sub Cntr Environroental enStilt, Address Sti.je IOC/ City Mt.! 551 Llo Lic# Phone# 1051- E191,- 5i Se <br />3IS Coordinates: X NA , Y Township NA Range Section <br />NORK TO BE PERFORMED: <br />g/NEW WELL / BORING ( CPT, pEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />gt CIL BORING # C1P-01 -- C1P- ID 0 0/ER-BORE <br />0 WELL # 0 PRESSURE CIROUT <br />'Other: Grout Specifications: <br />COMMENTS Ten OD-) Al leCt - p Lts.h ScI \ b or i_vv)S <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 3" MULTIPLE CASINGS? 0 MULTI-LEVEL? [] VELL CASING DIA: <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 1:1 PVC 0 CrHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 0—N1>TO TREMIE PIPE TO BE USED: a AUGERS 0 HE <br />I] AIR SPAR GE / Ozone lyKuSH POINT GROUT SEAL PUMPED: 0 sits 0 No (NOTE: MAXIMUM FREE- LL DEPTH 30') <br />EA561E. BORING 0 HAND AUGER GROUT SPECIFICATICNS: tet•A dt...t.pJ AA,- 54 ,Nt.12, - <br />0 OTHER: 1:1 OTHER APPROX. BORING DEPTH 15 ' IDT5 0 BOLTED T <br />,, <br />FFIC BCX or 0 S CVE PIPE <br />( <br />/ CONDUCTOR CASING P OPOSED? ( if YES, I. t specitcations here): <br />a -e-5 *COMMENTS: „en( O ouza <br />f <br />, it.%( <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 Ordinances Rules and Re ations, and all applicable California State Laws. <br />Prci‘ec-t- Ma-hcL3e 1 <br />Signed x Title/Company Delta_ EnviironyvIcatal jAe <br />9/a.3/02_, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2—l/ 6_inefi,64 <br />Date Issued Area 66.?' <br />• <br />Date Final Inspection Date /-4 —o3 <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />2 ,- <br />i-ft.+ -,,, Iv aA---- s' ii ZS 0 22- <br />C-57 WC I -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit.i.. Encroachment doc <br /> <br />8/29/02 <br /> <br />Print Name KeAtil KykeKe , Date <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: