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b <br />WELL I RMIT APPLICATION FOIIPM <br />FtiVikrY.E.N.0 Ai. Filii_l 1 i SAN JOAQUIN COUNTY <br />PT --R\II NVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />pm L4Ni E. Weber, Third Floor, Stockton, CA., 95202 <br />0 2 SEP I 6 (209) 468-3449 - <br /> <br />SITE <br />MITIGATION <br />U NIT IV <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />plication 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 />aquirty\inty.D.evelopment T)tle, C pt 9-1115.3 and the Standards of Si.il Joaquin County Environmental Health Department. <br />Assessors <br />ELL Location 14;14.1'04.m) Cross Street 4 ••' City •S*Ge/A11-1 Zip/62 parcel# 3)2-- <br />rovti c ____- 4, . , --- zii ,--3-bo 0 <br />;OPERT( Owner 5-/9/) joaf m./A (16 Address90, L._ _/-/_ _/12WW5:711,6 -41tri Zip 9Ld1 Phone# <br />. / /j ll'i'ffl-440C-/ •i0•7? <br />)ti "-- . . c rilit- Address 9.50 la ow6.- A-0,e.— City 57 Contractor6( <br />,nsultant / Sub Contractor /C)-(:7 Address g_3 7 —5-i)4 e/--- city _S---19 c_420,4 Phone# 171b7 <br />S Coordinates: X , Y , Township Range Section <br />DRK TO BE PERFORMED: <br />'JEW WELL! BORING (OLL-, GEOPROBE, HYDROPUKH, HAN90-AU;IV, R, OTFIE1r) <br />SOIL BORING # <br />WELL # <br />a DESTRUCTION (choose type below) <br />a OVER-BORE <br />a PRESSURE GROUT <br />ther: <br />DMMENTS: <br /> <br />Grout Specifications: <br /> <br />PE OF WELL <br />v1ONITORING <br />EXTRACTION <br />/APOR <br />AIR SPARGE <br />SOIL BORING <br />)THER: <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />El AIR HAMMER/DRIVEN <br />fl MUD ROTARY <br />0 PUSH POINT <br />fl HAND AUGER <br />OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2-I h MULTIPLE CASINGS? a YES a NO WELL CASING DIA: <br />CASING THICKNESS /V/4 TYPE OF CASING: STEEL PVC 0 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 7010SE <br />GROUT SEAL PUMPED: gYes No (NOJE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: 1D--4/c1 7.),e-- <br />APPROX. BORING DEPTH /5D reC---1— a BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR OASING,PROPOSED? ( if YES, list specifications here): <br />z- T 7, <br />OMMENTS: DO 1 I <br /> <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 />iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />lunty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />3ned x 40,11—> 'Title/Company /Me <br />nt Name W/))leILA_ ()/-We> Date <br />DEPARTMENT USE ONLY <br />TE MAP IN UNIT IV FILE, ADDRESS: <br />ORK PLAN DATED: <br />Zip9V--;--73Licr5it5Phone#25 31.2 520 <br />)plication Accepted By Date Issued Vol--3/ Area LO P <br />Date Final Inspection By Date <br />Date <br />out Inspection By <br />3struction Inspection By <br />DMMENTS / CONDMONS: 5 C-Fri <br />ACCOUNTING ONLY: AID# CArif <br />3E CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # <br />_ <br />INVOICE <br />)1ziOD _14-te_ _1/"/ D-1- SR# Do 31 251 0 <br />-57 WC -WAIVER <br /> <br />0-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />1125/0 <br />