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WELL RMIT APPLICATION FOWII . <br /> R: :a m •- �' 3; . I MITIGATION <br /> C SAN ,lPAQUIN COUNTY Ik ,ii. UNIT IV <br /> JUN "1 0 2003 ENVIRONMENTAL HEALTH DEPARTMENT.(EHD) <br /> 1 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT 4'4"LTH _ (209) 468-3449 <br />!, PERMIT/SERVICES V <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSiJED <br /> )plication 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 /> aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> .,r ` p Assessor's <br />+' ELL Location o3� S. - Cross Street IN City ! Cf 0.i 770 IS3 Parcel, 111,5 !! <br /> ZOPERTY Owner\0 f- -Address Q y 1 G Zip l•a�aPhone#2L `4LWo6C& <br /> 1 - C G. <br /> "57 Contractorlcr%vt rt] ��R. Address 331 S . M:tetli oma. cityLS!/�&AeiiIIvl Zip', 0(tLic#696b)a7pnone# 7/y -?f6—,5(5 <br /> �^ IIS <br /> I )nsultarrt/Sub Cntr /►C L�� I[3 Address S ' �a'� City �1L -Lldito <br /> 2m-aJ7 Phone#Wq—'W,C7`1 G10I- <br /> Nv R;TP—W lw k <br /> S Coordinates:X Y Township Range Section <br /> ORI(TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROP,JNCH,HAND-j%UGER,OTHER-) � `,. .;,`` p DESTRUCTION(choose type below) <br /> }'SOIL BORING# t -S7-1/ DB-2-,, LL -�S , '„ p OVER-BORE <br /> 1]WELL# a PRESSURE GROUT <br /> Khen AUnn.bsr S w; er r+� Grout Specifications:SLrU ����� __ l <br /> )MMENTS Cr-. o Se ;c- c4e,r+ �h <br /> PE OF WELL- INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING U HOLLOW STEM RIA OF BOREHOLEI 2S MULTIPLE CASINGS?a MULTI-LEVEL?© WELL CASING DEA: <br />{ -XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC II OTHER: <br /> 4 VAPOR o MUD ROTARY DEPTH OF GROUT SEALTU iTREMIE�TYPI=TO BE USED: []AUGERS U HOSE <br /> AIR SPARGE I Ozone PUSH POINT GROUT SEAL PUMPED: p Yes %lo (N'OTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> $OIL BORING Q HAND AUGER GROUT SPECIFICATIONS: A �k«4 `�O <br /> OTHER: n OTHER APPROX,BORING DEFrH ��' eei qSA p BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> is <br /> CONDUCTOR CASING PROPOSED? _(if YES,lists <br /> `rt rations here): <br />{ :oMMENTs: �2r P� S �v►�` (.Jor fel tJ(o ung <br /> :Ii :�' <br /> i NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS.- <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> f zereby ce t t 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> ounty O UI s an Regulations, and all applicable California S to Laws. ! <br /> f fined Title/Company , CIP� Geo n j i rpvlM'a4 <br /> k <br /> int N e l,�c r"1.l 1 t' il" Date JU Ile o1.01: ) <br /> DEPARTMENT USE ONLYi 1� <br /> xf?ITE MAP IN UNIT IV FILE,ADDRESS: !� s• III SII u�a l <br /> IORK PLAN DATED: <br /> I" *plication Acte"pted By, Date Issued ' Area <br /> rout Inspection By Date Final Inspection By ale <br /> astruclon Inspection By Date <br /> OMMENTS I CONDITIONS: II II <br /> iIV <br /> ACCOUNTING ONLY: AID# ti <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE Ii PE MITI SERVICE REQUEST#" INVOICE <br /> 00 3 7,(o Z-. <br /> :-57 WC -WAIVER C-57 Letter of Authorization to sign perr'llit Encroachment do $/29/02 <br />