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WELL. PrRMI , APPLICATION Fro M <br /> SITE <br /> I,-���'SAN`JOA UIN COUNTY MITIGATION <br /> G <br /> / � �xo ,,� E VIRONMENTAL HEALTH DEPARTMZM(&D) UNIT !V <br /> 4 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> W v)t NON-RE <br /> FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> mtion is hereby made to San Joaquin County for a permit to construe,and/or install the work described. This application is made in compliance with San <br /> in County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department_ <br /> Location 621,3 w. C I a S f Cross Street M04r-O f, Assessor's <br /> - City hoc 1`+on Zip $a?0(o Parcel# <br /> 'ERTYOwner� Address 3qW. Cj.�,, St c; S-+'ock}on <br /> /� city Zip9�(�b Phone# 9`lrY'030z. <br /> ;ontractor ease drenn Address 3 6& c <br /> 63 - Ornec C;rc le C;ty ,+ hv Zip `�S7y1Lic# 71 O Phone#9/(O�e38- II(oI <br /> iltant I Sub Cntr ALM c ed neco Address'�3-� S1xGj —city--5 K- Lie#__ Phone# yl'o?-/00(0 <br /> 2orainates:X ,Y Township Range Section <br /> TO BE PERFORMED: <br /> N INEi1/BORING(CPT, GEOPROBE,HYDROPUNCH,HANC-AUGER, OTHER-) $DESTRUCTION (choose type below) <br /> SOIL BORING# COVER-BORE <br /> [ IJ�Nc�$ [] PRESSURE GROUT <br /> 5- t`J- 1 Grout Specifications: �/►+Cn4- 1�ClIG <br /> RENTS <br /> DF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IITCRING 0 HOLLOW STEM CIA- OF BOREHOLE MULTIPLE CASINGS? 0 MULTI-LEVEL?Q WELL CASING CIA:__ <br /> 2ACTION 0 AIR HAMME.WDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL V PVC 0 OTHER: <br /> DR 0 MUD ROTARY DEPTH OF GROUT SEAL TD TREMIE TYPE TO BE USED: [I AUGERS 0 HOSE <br /> SPARGE/Czone 0 PUSH POINT GROUT SEAL PUMPED: Q Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> BORING 0 HAND AUGER GROUT SPECIFICATIONS: Zen' or,•�, 4o TZ) <br /> .R: _jJ OTHER APPROX.BORING DEPTH 3(0` BOLTED TRAFFIC BOX or STOVE FIFE <br /> CONDUCTOR CASING PRCPOSED? (if YES,list specifications here): <br /> 1ENTS:�DFJ_ 3 of borir` , 1nb� Too <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 /> by certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :y Or a est, Rules and Regulations, and all applicable California State Laws. <br /> ' <br /> -Fide/Company 44R—AL A G <br /> ,me_ �rt34-oq�ee- (L . r).' Her Date (l' t3.U3 <br /> DEPARTMENT USE ONLY <br /> dc-� <br /> AAP IN UNIT IV FILE, ADDRESS: i . <br /> C PLAN DATED: '� <br /> ion Accepted By Date Issued �� Area <br /> spection By e final Inspection By Date <br /> don Inspection By Da <br /> _NTS I CONDMONS: V- zlyl <br /> IUNTING ONLY: AID# vL d r C +w) <br /> )DES FEE INFO AMOUNT REMITTED CHECK# REC'D Y DA PERMIT!SERVICE REQUEST# INVOICE <br /> DZ .®O1 11 - Z <br /> — WC -WAIVER C-57 Letter of Authorization t sig permit Encroachment doc 8/29/02 <br />