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^.9Y-19-2002 16: 111 FROM:MWH GLOBG� 916 419 8522 TO P 4683433 P.2,2 <br /> urn e), sear •+vn aa. c� crq car .» ��� cn� Ib'Jua6/ wo, <br /> t+ San Joaquin County <br /> N ' Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468.3449 Fax: (209)468-3433 Web: www.sjguv.org/chd UNIT IV <br /> Well Permit Application CCi3—(c) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby mode to sari Joaquin Counly for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Tilte,Chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Locatlo '54j r- AIr- AVIV. ./U,J GII SmckXON Assassors n/ <br /> Cross Street WaS�irwd y Zip 79S aS_ParceW .vi} ( p, ref GAj, <br /> aY <br /> - PROPEHTY �� <br /> Owner SA.a 2*41614 Cry"Ty Address-/V 0 IFAZie44W At/C' Ciry. $Tj,*Aw Zip4hones Obs-3aoo <br /> - C-67Contractor 9&T Ardlr Js �—Address Zz0A1-LrAST SP. Cilyubod/W-.A Zip4f'776 LfWI0Z7J Phone STD brig^24 ZJF <br /> Consultant/sub Cnlr ldA LJ II/}icnerttl4 y?LAddrcsa (z_g,Ner;L,,,,,1 Rd. CIry S.4C. ur '4 Phoni+9•BSS¢ <br /> �u <br /> GIs Coordlnatea:X Y ,Township Range Section <br /> VVORK T ERF <br /> ?OEWWELL BORING 11 <br /> P GEOPROB IHYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> Yp WEILLIr G 1 y2� -til-r� �.)``yS 8 0 OVERBORE DIAMETER <br /> �RESSURE GROUT <br /> a Other GROUT SPECIFICATIONS <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (I MONITORING a HOLLOW STEM DIA-OF BOREHOLEn Q MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION p AIR HAMMER DRIVEN CASING THICKNESS Arh TYPE OF CASING- a STEEL a PVC U OTHER: <br /> 0 VAPOR 0 MUD ROTARY� DEPTH OF GROAT SEAL Trfal�wr�TREWIF TYPE TO BE USED;-AUGERS a HOSE <br /> a AIR SPARGE!OZONE PUSH POIN7(oorCPT)GROUT SEAL PUMPED: U Yes gNo (NOTE; MAXIMUM FREE-FALL DEPTH IS SO') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS Po✓T/ ri(pg. S SIS A1�-�' Cgr.w„��" <br /> a OTHER:-0 OTHER APPROK BORING DEPT M B¢ a BOLTED TRAFFIC BOX or �STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED AIA (if YES,list 1515ak10oatlons in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances,RUISS and Regulations, and all applicable California..State Laws.. i -y ' <br /> Signed x - Titlelcompanyy_//�GVFr IYN+030t1�.�-.�/4 <br /> Print Name ICIPJd Dant <br /> DEPARTMENT USE ONLY f T <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /SG <br /> WORK PLAN DATED: <br /> Application Accepted By LL C-2 Date Issued_ 7 07 <br /> ,/IArea <br /> Grout Inspection By_ [`c'L�•^b� Oala 'v C Final Inspection By Date <br /> zilb <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: n-- ( <br /> ACCOUNTING ONLY AIC4 FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'0 BV DATE PERMIT!SERVICE REQUEST q INVOICE <br /> b `[� (b7� l�fC �il� SR#poslXb <br /> C-57_ WC_--WAIVER C-57 Letter of Authorization to sign permit` Encroachment doc! <br />