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WELAERMITAPPLICATION ^I►A <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <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 and the Standards ofSanJoaquin County Environmental Health Department. <br /> WELL Location G'ID �{/. f /JAa?m t/ ,�9_ Cross Street /die'-K_ J'y 6_ L G Assessors <br /> PROPERTY Owner�/(�F71/ S C-•"a_^ City ` (' ern- ZiP T'rCld Z"Parcel# <br /> A v Address 67-0 �/- �TOD U/ Y ,s <br /> C-57 Contractor/?G E <br /> Addressl,37 Masi) City -S G _ZiP >`ll c#1o90L7. Phone# </ 7-4'r <br /> Consultant/Sub Cntr Address�,j? ,5�, a� y�jy <br /> /City�7�jcyV Lic O Z, Phone# <br /> GIS Coordinates:X ,Y Township <br /> Range Section <br /> WORK TO BE PERFORMED, <br /> 0 NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> )dSOIL BORING# $-/ g-z p DESTRUCTION(choose type below) <br /> 0 WELL# 0 OVER-BORE <br /> 'Other: <br /> COMMENTS Grout Specifications: 0 PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ' ' <br /> [)EXTRACTION 21_MULTIPLE CASINGS?11 MULTI-LEVEL?0 WELL CASING DIA: /�� <br /> AIR HAMMER/DRIVEN CASING THICKNESS ,VA- TYPE OF CASING: 0 STEEL 0 PVC <br /> eZa / BOTHER: /V1-F_OTHER: Ni? <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE/Ozone PUSH POINT E TYPE TOUSED: 0 AUGERS HOSE <br /> GROUT SEAL PUMPED: []Yes B1Vo (NOTE: <br /> MAXIMUM <br /> FREE-FALL DEPTH IS 30') <br /> SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: t'o 1J7Z,1rd �L�7.•••�•r7✓ <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTHQ / <br /> 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? <br /> *COMMENTS: .CJ/��'S �jR- plsA„J�„u�yr�•yu7-of7` (C —�0- (if YE�Sj,lisl sp cifications here): <br /> L0.2U?$ Inc!' ZKgt� <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 re ared this a lication and that the work will be done in accordance with San Joaquin <br /> County Or4krimlces, les an Regulatio 1s d all applicable California State Laws. <br /> Signedx Titie/Company <br /> Print Name SIN Date 9 3U dL <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATE`I/D:: <br /> Application Accepted By V NI�/ /�L <br /> Are <br /> --�� d_ G a <br /> Grout Inspection BDate Issue <br /> y Date Final Inspection ByT <br /> Dale <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: Ck9 e0n ®Su- ,-0 V*" e. G <br /> ACCOUNTING ONLY: AID# T <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> l S h p a t <br /> C-57_ WC--WAIVER— C-57 Letter of Authorfnation to sign permit_Encroachment doc_ 8/29/02 <br />