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SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Date Issued <br />Final Inspection By <br />ZOO e a <br />-4 A2-ate <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date <br />Date <br />WELLIERMIT APPLICATION HIM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <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 />PAciF ' „ Assessor's <br />WELL Location c-.7(11C1) ppr ifiL /4 ‘Cross Street CAsittl, 51- • 'City Tt.N. 1-0 n Zip 95241 Parcel# <br />VO1 N 1) ( '114-01 <br />PROPERTY Owner c DA via opf4marrerAddress p, , GO ;c HO City S Tsr..(i 9r) Zip 95Z0 1 Phone# V65 3Y 2 / <br />n,RANci4 0 <br />C-57 Contractor C,if' 5(.4 if- A Jul Address3b3 ()M EC C irOe City coaRDebvA Ziplg 7'/- Lic# 71 751,3 Phone#0963i- <br />k 0 y ,s 1 <br />Consultant / Sub Cntr A ,.#ii,„ken E.„„:Jonaun 'Address 7 -5-A199‘4., Al City 571>Likrr4n Lic# (01)-c>Z_ Z. 7 Phone# Dcl yk 7 tool° <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />)(NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />a SOIL BORING # I] OVER-BORE <br />K/V ELL # /V) ini -/ 3 B PRESSURE GROUT <br />*Other:').•)• Grout Specifications: <br />COMMENTS Rr_pktc ?erw,(1 1- OF lAizit mw-,3 7 si_ A ppPt....-40 ‘,.., 00-1( ple„-, DGk,o, ZZ. j,,I-, Z,),?... --P... <br />0 <br />SQ <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ONITORING **HOLLOW STEM l] <br />0 <br />AIR HAMMER/DRIVEN DIA. OF BOREHOLE 0" MULTIPLE CASINGS11ULTI-LEVEL? WELL CASING DIA: <br />0 EXTRACTION CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC AOTHER: reo otv <br />El VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 9 a Fa. 4- TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />U AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: "Yes g No (NOTE: MAXIMUM FREE - ALL .DEPTH .IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: i CA TI ON () 7-y p T (hi/ 5e/c Of 4.41 Pm ill <br />0 OTHER: B OTHER APPROX. BORING DEPTH /91 F---,- MOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? Ni "4 (if YES, list specifications here): <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 Californi ate Laws. <br />Signed x Title/Company L7 QtAs, <br />1 D v //ilk <br />' DEPARTMENT USE ONLY <br />Print Name Date / 0/0 9 / n 2_ <br />COMMENTS / CONDITIONS - , <br />ACCOUNTING ONLY: AID# <br />-, <br />Ot8/6,—g.i <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERM!r • INVOICE <br />33-0i 9?,00 I-5---sq q;ionVoz ...„-,- I .....- s- -s <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />8/29/02 <br />