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WELL i _RMIT APPLICATION FO. _-A <br />a <br />1R1ECmyE`E��)) SAN <br />NVIRONMENTALOHEALTH DEPARTMENT EHD <br />AUG 2 2 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />ENVIRONMENT HEALTH WINIU11WA L <br />PERMIT/SERYICg NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to an oaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Developmen <br />t Title, Cyh9pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location/ f 1�' ' iQt Cross Street 1 city, 1204e Zip 7S �-%�C/Parcel#�rr,� <br />PROPERTY Owner /° Address T I U 1 City/ -/�/� Cly} ZIP152' �'hone#i �l't/ <br />C-57 Contractondiv, �. zr(/Ir, Address_��I �L(/�C Ci iU(' l4'N Zip I� Lic# 'honep:�67-110�G� <br />Consultant /Sub CntrdN/, & t) AC/✓l! Address 5 7� JA21a CityLic# Phone# :t2 7 -�UU <br />v <br />GIS Coordinates: X <br />Y <br />Township <br />WORK TO BE PE}E9UED: <br />/'NEW WELL /'.PORING%( CF'T( G PROB , HYDROPUNCH, HANG -AUGER, OTHER*) <br />XSOIL BORING #. <br />0 WELL # <br />*Other: <br />COMMENTS <br />Grout <br />Range <br />Section <br />>3 DESTRUCTION (choose type below) <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE jr MULTIPLE CASINGS? 0 MULTI-LEVEL? fj WELL CASING DIA:j�JA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS /t TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER:___ <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />0 AIR SPARGE / OZone)(PUSH POINT GROUT SEAL PUMPED: 0 Yes 'g -No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ;�'�f�tiD /'c"�v�yi ���-O To .GGrAL 111z c' <br />0 OTHER: p OTHER APPROX. BORING DEPTH ii f 0 BOLTED TRAFFIC BOX/., 0 STOVE PIPE <br />_ / CONDUCTOR CASING PROPOSED? N,� _ (if YES, list specifi-Etat-ions here): <br />*COMMENTS: / i�y �/ reCL Aet r as :1"l Z�;'% <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />Count Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signedx� ����j� l I � Title/Company �4�U-24i .S %T-/ <br />Print Name I X'l V1 I P,1 I,C C'1 [ lti� JC 1,1.1 Date <br />DEPARTMENT USE ONLY <br />SITF MAP IN UNIT IV FILE AnnRFSS: 1 n 4 \A/ Dever 1 u P101--e- <br />WORK <br />la1-_e <br />WORK PLAN DATED: / \Januarw411-200D <br />Application Accepted By V 1 L� p Y f 0, NtG � ri- (P�1 Date Issued ?$ _-Z003 Area )4E <br />Grout Inspection By �� E�2ta_•` i� Date /z( �' Final Inspection By ; n.c'�lr%%jam/ � 1i Date <br />Destruction Inspection By Date - <br />COMMENTS / CONDITIONS: Tris+a 11 2 bori r,4 s - B 23 a md 1324 ,i+1,e S+reet ',Iq Sro of df ho "e5 et 41 and 113 Beer l y Plaee, <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO I <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / SER EST # <br />INVOICE <br />3501 <br />89.00 <br />�99,0� <br />19%�� <br />SR 0034993 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroac men_td ac 8/29/02 <br />