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WE6.ePERMIT AIPPLICATION ,,,,,SRM <br /> 16 , SITE <br /> VV <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD)`:;�r - <br /> 304 E. Weber, Third Floor, Stockton, CA., 96202„ <br /> (209) 468-3449 FILE COPY <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 /> � " `` `` Assessor's <br /> WELL LocationiSo k fflw, /Ilma 2� Ws Cross Street City c��Ltfiv� Zip 2?a Parcel# <br /> PROPERTY Ownierzr. ,_i� YV�C(�l�E(SGut Addressly5f .U.6sr+u«� lit City�{t&k -- Zip�s2/S Phone#q <br /> C-57 Contractor 1�4IAJ Address 1,1h st" ' -&A City / _Zip c1�l Lic#_7wLQgPhone'//�)��x'1/100 <br /> Consultant/Sub Contractor �.� _Address City6C1A-1 Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> (NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> W ELL# fr1�/LA�J �,4) Grout Specifications:. 0 PRESSURE GROUT <br /> 'Other: fcations: �1:� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPFtCCIIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE ZS iALtl1 MULTIPLE CASINGS?0 YES XNO WELL CASING DIA: l tAt <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: 0 STEEL `(,PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL %,fit TREMIE TYPE TO BE USED: )<4UGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 'gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUTS PEC IFI CATION S: f <br /> 0 OTHER:_ 0 OTHER APPROX.BORING I FIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AJO (if YES,list specifications here): <br /> `COMMENTS: <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 /> County Or in , Rules and Regulations, and all applicable California `S,t-a(tee Laws. <br /> i_ <br /> Signed x Title/CompanyQ4 <br /> ID/ �}l <br /> Print Name _LlA( (G '1'ryo c l Date " 3 ; 20IR <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1501 V GOA <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued ` — �■ Area 06 <br /> Grout Inspection By Date Final Inspection By XUate6_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3�l 8� D ov 75. 2 3D o0 <br /> C-57 WC,/-WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />