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,111 L PERMIT APPLICATION FORM SITE <br />Pi SAN JOAQUIN <br />COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />04 APR 28 P14 43W. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 R t 1_N , " <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 complrance w <br />San Joaquin County Development - itl Chapter 9-1115.3 and the Std ards of San Joaquin County Environmental Health Department, <br />_ -` � Assessors (�C/� �/�� <br />WELL L9catiun C Cross Street ! 4-2 1& City ZIP �] ✓ l/ wV 9 <br />Parcel# J <br />y <br />PROPERTY/AA+//� J �7 7 3 J—Lj( � ?L/ <br />Owner / "IC I F�iC _Address- City47�Z aPhone# l 1 j <br />C-57 Contractor f4i Q.W&5— ` Address - b, V ` f City fdYl ('G Zip�7�LictP-+y� Phone# 530 _2 ?- ZO <br />ConsultantISubCntr Kle111 e�C� Address��z� C, �IV�7'� Ci�_Lic# Phone# 7 '/n J <br />GIS Coordinates: X Y Township Range <br />Section <br />WORK TO BE PERFORMED: <br />[] NEIN WELL / BORING (CP , HYDROPUNCH, HAND -AUGER, OTHER") <br />0 SOIL BORING # <br />DIAMETER <br />0 WELL # <br />0 "Other CQ <br />SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />0 MONITORING <br />IN$TALLATION TYPE <br />p HOLLOW STEM <br />p DESTRUCTION (Choose type below) <br />0 OVER -BORE. <br />0 PRESSURE GROUT <br />E -GROUT -�rQ� S�,mzftc <br />�,/i* crumb stwns <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA-- <br />Q <br />IA: <br />Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING a STEEL 0 PVC flOTHER-. <br />D VAPORp UD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE U5ED: Q AUGERS p H( <br />0 AIR SPARGE/ OZONE PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes 0 No <br />OTE: MAXIMUM E -FALL DEPTH IS 30') <br />SOIL B RIN 0 HAND AUGER GROUT SPECIFICATIONS_ V UIr` <br />OTHER: D� T OTHER APPROX. BORING DEPTH �� 0 BOLIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED A r Ar (if YES. list specifications in comment <br />I hereby cert that I ave repared this application and that the work will be done in accordance wi h Sart Joaquin <br />County Ordi a ce ule nd Regulations, and all applicable Califo a State Laws. <br />Signed x 'T e/Company I Z°c <br />Print Name ` Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />Grout Inspection By_ <br />Destructionlnsoectio <br />COMMENTS / CONDITIONS: <br />Date Issued <br />to Final Inspection By <br />Date V�- <br />Area <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D 9Y <br />DATE <br />RMIT / SERVICE REQU INVOICE <br />-12 <br />,107 <br />SR 3 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign per M-1 chment eN 9/30/02 <br />