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WELL i _RMIT APPLICATION FO. -A SITE <br />MITIGATION <br />SAN JOAQUIN CO'UIV'P( ;',!}[' <br />ENVIRONMENTAL HEALTH DEPARTMENT EHD) ���� I� <br />CR I` A L 304 E. Weber Third FIoob�$GUfi)r>P : L43 202 <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 anc the Standards of San Joaquin County Environmental Health Department. Assessor' <br />© jaGl '� & `� tycog-MAssessor, J <br />WELL Location /'/ ! Cross Street Ci _�j�[�p Parcel# <br />PROPERTY Owner V I Address 72Y ? �/j �Cityr` ZC� ✓1 TZp /�/ Phone# l�z — 6� , <br />C-57 Contra �-{ Address y I WU //J,�U,� City "'f��LrR�_l'ti'`jp.7phone�� 3J - 590 <br />Consul t / Sub Cntr l� L� Address ? �, �'`�\i ok City i/ �[ !C� Z Lic# Phone �(6 71&66 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />jKEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HANC-AUGER, OTHER") >3 DESTRUCTION (choose type below) <br />,2§0IL BORING # 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />`Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone KUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER: rl OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA- OF BOREHOLc2_ "ULTIPLE CASINGS? 0 MULTI-LEVEL? [I WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 FVC 0 OTHER: _ Q <br />DEPTH OF GROUT SEAL / GAJ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE U <br />GROUT SEAL PUMPED: Yes �p �No/ (NOT MAXIMUM FREE -FALL DEPTH IS 30') u <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />t <br />CONDUCTOR CASING PROPOSED? <br />#.#)MMENTS: / �` ��� e% — 5,/�— C SSC?fS�•��< <br />( if YES, list specifications here): <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 Regulations, and all applicable California State Laws. <br />Signed xLG A97'4— Title/Company <br />Print Name l�fi�% / �ni�/�� Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />lication Accepted B t o jl i b S 2 00 3 Area % 4 s <br />App' p y M G r`he_� Date Issued N r7 �/Eyyi!?r <br />Grout Inspection By V iGty.;e. L. 1 Yi�(�r{ �i Date .12 - 6-0 3 Final Inspection By�'i' , ; d ill / ­4 r i71e,� Date <br />Destruction Inspection ByDate <br />AA <br />COMMENTS /CONDITIONS: /10(✓dn C p- 3 C', l° i d u,&1 bn ri Y -Las ±6 I I l) -feed' d e��o C�°T' l - 2, ' 3 <br />0 <br />C <br />ACCOUNTING ONLY: AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE # <br />INVOICE <br />3501 <br />$q,60 <br />�"v <br />�� � <br />SR 0035433 <br />C-57 WC WAIVER C-57 Letter of Authorization to sign permit �h&oachment_doC 8/29/02 <br />