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WELL _RMIT APPLICATION FOODI <br />OCT - 1 2003 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRONMEN1 HEALI hs 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERVORI <br />1 o0"%°1 l NAL <br />I ' <br /> <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />Cross Street •,v 9,5 T Lvir•ifil City 5 Mc.K Tr.„•\ Zip (-)5:4? 7 Parcel# <br />Address P 11.3L. //a A city -31-ccK 7?),^I 95,?t,/ Phone# (_()) Y(06-0/c. <br />151, <br /> Address 7 •St-P) /W cityS rcteri.),-1 Lic# 6,8-0d:97 Phone4 La 7 / <br />with San <br />WELL Location 3,-Z-5C i\J kAi '5 (./live:- <br />PROPERTY Owner ti+9A) <br />C-57 Contractor Arl r #11, ,ct, <br />J <br />Consultant / Sub CnIr A• <br />ic)(4/.9- z z 4- <br />Address <br />f <br />intlat C ,41P (--4 City (.;;,,q,".„ Zip`;54 Lictt t 7Phone147 C..)C3 /5533 <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />VEW WELL /6-0T-RIICISDCPT, GEOPROBE, HYDROPUNCH, HAND-AUGER OTHER) <br />XSOIL BORING # P&P I P-/ c e p 117 f- -I 2- <br />fl WELL # <br />0 DESTRUCTION (choose type below) <br />OVER-BORE <br />0 PRESSURE GROUT <br />*Other: Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 7kOLLOW STEM DIA. OF BOREHOLE 9.'' MULTIPLE CASINGS? a MULTI-LEVEL? U WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NO- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: /vie" <br />0 VAPOR 1:1 MUD ROTARY DEPTH OF GROUT SEAL"/ DI`‹ P ii-1 TREMIE TYPE TO BE USED: UGERS 0 HOSE <br />U AIR SPARGE I Ozone 0 PUSH POINT GROUT SEAL PUMPED: 75'es Vio (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />. y\SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: 4, rbp, ND -1-7PE <br />o OTHER: TI OTHER APPROX. BORING DEPTH Si Ffrs E. r a BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ^46 ( if YES, list specifications here): <br />*COMMENTS: 5EL (A) 0 AK pie.),,„ I Of , FE 0 cy3 id, .2.., j <br />I <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 />Signed x <br />County Ordi ances, Rules And Regulations, and all applicable California State Laws. <br />/i. <br /> <br />ocilici/c13 <br /> <br />Print Name C <br /> <br />Date <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 82 30 j\I 0 Le-1 ,1c <br /> <br />WORK PLAN DATED: \it ) u. 3 2003 <br />) <br /> <br />Application Accepted By V I :t-C) 4 L, j4 rei rfh q Date Issued IC - 2 -6'3 Area <br />Grout Inspection By kko40-i y......7 Date /O 9 - 3 Vt. Final Inspection By Vie„4-ty;41., 111 tear Date • 0 3 <br />Destruction Inspection By Date <br />COMMENTS I CONDITIONS: bc •P-6 P-cAI ell <br /> <br />Title/Company <br />ACCOUNTING ONLY: AID# <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE T # INVOICE <br />3 5 Ci I 8100 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign pe Mit------E-ncroachment doc- <br /> <br />8/29/02 <br /> <br />41,