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<br />Jp\ "P(17 WELAERMIT APPLICATION AM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br /> <br /> <br /> SITE <br />MITIGATION <br />UNIT IV <br /> <br />JAN 20 2001 <br />ENVIRONfvkH, <br />PERMIT/SL, <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 />Assessorsr.1 <br />WELL Locations AL,e,-)cAe._ Cross Street :?:%,"4e-T- City Lr4en Zip ml A Parcel# <br />„.,A <br /> <br />(c..) re (307s, kcsct <br />PROPERTY Owner (-<-(c• %We_ C= Address ftS0 1:1,s-1 on <br />t <br />Bigot. S&City gocisicel13< ZipRkS Phonei-S-It Cal <br />C-57 Contractor r- Addressc? SC) 12.c:t City/t4o04 /It? Zip'( 66S Lic# friLS1C5 Phonek(97-,5313 -.5600 <br />Consultant / Sub Cntr ;cc Address24 City-Sc "zor.-A. Lic# 1:ks Phone# `ix5 --(1-6-5c) <br />GIS Coordinates: X A//A , /' Township N/A / 5106 N <br />Range Section A//4 <br />WORK TO BE PERFORMED: <br />-11 NEW WELL! BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />[] SOIL BORING # <br />'flWELL # <br />[] *Other <br />COMMENTS: <br />DESTRUCTION (choose type below) <br />[J OVER-BORE. DIAMETER <br />PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />1/MONITORING <br />[] EXTRACTION <br />[] VAPOR <br />[] AIR SPARGE] <br />[] SOIL BORING <br />[] OTHER: <br />COMMENTS: <br />NOTE: <br />CONSTRUCTION SPECIFICATIONS it <br />DIA. OF BOREHOLE ¶ []MULTIPLE CASINGS [1 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS-- ec, TYPE OF CASING: [] STEEL gPVC [] OTHER: <br />DEPTH OF GROUT SEAL -40 TREMIE TYPE TO BE USED: ,RAUGERS UHOSE <br />[] PUSH POINT (GP or CPT) GROUT SEAL PUMPED: RYes [] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS Fbf--4 (c1,..iot Ca.r. ),..,-) EL-n-4 ----61. <br />[] OTHER APPROX. BORING DEPTH 'El° 1 ,WOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED A/0 (if YES, list specifications in comment section) <br />OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />INSTALLATION TYPE <br />-,11._HOLLOW STEM <br />[] AIR HAMMER/DRIVEN <br />[)MUD ROTARY <br />OZONE <br />7 t.--(e.c.r) %• /1 Co. r,--1 4)r- a 11 tA-)C 14 qr1 5 <br />48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinance les and Regulations, and all applicable California State Laws. <br />toru- 77 e 6.-Y40% Signed x Title/Company / aAckepee-Av <br />Date Aria y <br />SITE MAP IN UNIT IV FILE, ADDRES1: 613i p <br />WORK PLAN DATED: J o 3 <br /> <br />GuiA.A <br /> <br />Application Accepted By (.14.AAAC'et, <br />Grout Inspection By ,C.>1.AnAlc-1,^A Date 71010 Y <br />Destruction Inspection By Date <br />Date Issued Area <br />Final Inspection By I (4rtA4^ce:ft---N\ Date <br />COMMENTS / CONDITIONS <br />ACCOUNTING ONLY: AID#F. KRi--ir -'16‘ .733") <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY 11TE PERMIT/SE ft INVOICE <br />9 ° C2° ( S -3 1 i l(Af( i i 2- icy i SR# <br />Print Name Prue) er- <br />DEPARTMENT USE ONLY <br />C-57 WC -WAIVER C-57 Letter of Authorization to sin permit Encroachment doc <br /> <br />9/30/02 <br />