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WEL PERMIT APPLICATION V% ^M SITE <br /> c:it�'If�G'if`�fifJ(/~i. �IE11l.lfl SAN JOAQUIN COUNTY MITIGATION <br /> EWRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 03 JUL -9 ISA EI teber, Third Floor, Stockton, CA., 95202 UNIT IV <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 /> r,rr�ir' Assessors <br /> Vy�CL Location��i l l f i(� ;.r..I ll?(`� I I r / ` ` 3 i f <br /> Cross Street 1 ��C- City l%'r o r l., Zip Parcel# <br /> PROPERTY 8wner_�-il�l-irh � �JY"drfef'y" <br /> dss ; rT ^Cith , Zip' r,A,r_ Vii.-`r'- `'�,!-G✓.Y J <br /> Phone# <br /> C-57 Contractor 1lnG! Addressgi-p ��u.C. A&I hil Zi9#55j i 1`8514,5 Phone/# 5--3/3•-5(kc1L` <br /> ---- -_ , I � :, .I , <br /> Fonsultant ub CntrC)CI,n,,, I,; k� l f�'_-t�I Ptn1f t�Address'1( , I L FI City '(0{_ <br /> I rrY r) �,I <br /> i. Lic# Phone# <br /> GIS Coordinates:XY Township 1� Range Iy' Section <br /> WORK TO BE PERFORMED: <br /> ha N—_. =!,BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') �p�DESTRUCTION (choose type below) <br /> SOIL BORING# 41'1X-10 16 tu-(I (,A'1X-1J 0 OVER-BORE. DIAMETER <br /> B WELL# PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: i c I.IA1, c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSI\1 U411 <br /> B MONITORINGFiOLLOW STEM DIA.OF BOREHOLE _'N"a MULTIPLE CASINGS 0 MULTI-LEVEL WLL CASING DIA° <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESSv—' TYPE OF CASING: 0 STEEL 0 PVC B OTHER: A <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL111 I I _1`i(k�[ TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE/OZONE B PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'D;Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING B HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: G OTHER_ APPROX.BORING DEPTH _ <br /> _a-BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Kl '� (if YES,list specifications in comment section) <br /> COMMENTS.tA1�1 x'7,1 ;0('4'_, r;_,i�l+„I1G"Gti�t�1[i�(1�rllhri( .(Alf'i t ' C>riI 6 n/{ 6/9 k) o'0 "'d i,o/rt, trrll�plP' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> CounYeI4 <br /> nances, Rules and Regulations, and all applicable California State Laws. J L / <br /> SignedJ � t• Title/Company��' LC �(��� ��C�G�LJ lel L', <br /> Print N <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:/ �C✓�tOU Q��r �I/.�, � ,_,� <br /> Application Accepted By ^A (tel Date Issued -7//J/ 03 Areae <br /> Grout Inspection By Date r 2,10 3 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> s l r �+ D �� 7 1'7 c►� S R# D 6 7 <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />