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i <br /> .SEL PERiV11T APPLICATION (4RM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stacktoln, CA., 95202 <br /> (209) 468-3449 APR 18 2003 <br /> NON-REFUNDABLE PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED �t <br /> Application is hereby-made to San Joaquin County for a permit to construct and/or install the work described. This application s�mW&Gtl`Qti�n*,P4L)T,en <br /> Joaquin County Development Title,�Chapter 9-1115.3 <br /> 1115.3 and the Standards of San Joaquin County Environmental Health De artmeW- <br /> f � R�1 <br /> Asse s ;r u�RV'ILC <br /> WELL Location & Cross Street� City ,—a-, Zp X'C Parcel# <br /> PROPERTYOwne&JaC <br /> a���( _Address�_l k.l�2j&,4-ncs City!'uf(� ZiPhone# <br /> �� /,, 0 J <br /> C-57 Contractorm((Clf I jkjWA Address kl 14AM;yU l �City 11 Zip?L474 Lic#�1 hone#( � <br /> J% /3;- <br /> Consultant/Sub Cntr A ' t Address 93% SX&O ga _Cit� �T1�Lic#69J227 Phones#ne� L7- d dA <br /> GIS Coordinates:X Y Township Range Section <br /> . s <br /> WORK ERFORMED: V) <br /> E WELL BORING(CPT,GEOPROBE,HYD_ROPUNCH;HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> a SOIL BORING# CJ Q OVER-BORE C <br /> "ELL# (�(�tJ� (;q,;.LU- 914,LT}-� 944 LU�7 p PRESSURE GROUT <br /> 'Other: rout rout Specifications: <br /> COMMENTS , <br /> TYPE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �iC'NITORING HOLLOW STEM DIA.OF BOREHOLE j•2 f MULTIPLE CASINGS?a MULTI-LEVEL?a WELL CASING DIA:2 f` <br /> j]EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSTC/ 1('d -TYPE OF CASING: p STEEL %OVC 0 OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL r TREMIE TYPE TO BE USED: AUGERS HOSE= <br /> 1]AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED: p Yes KNo (NOTE: MAXIMUM FiREE-F \ALL DEPTH IS 30') <br /> j]SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: �} 7.'�. ?- Z .�Z t <br /> (]OTHER: n OTHER APPROX.BORING DEPTH,-,_, i/ �B&TEDTIkAFRCBOX cr G STOVE PIPE <br /> /I CONDUCTOR CASING PROPOSED? IwIC (if YES,list specifcxtions here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4B WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. (� <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br />' County 71, <br /> a es and Regulations, and all applicable California State Laws. <br /> Signed x ' Title/Company S D}N L -�f <br /> Print Name %�CI1j __ Dater" <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: D S e 00Q_ <br /> Application Accepted By ` Y/�Q�1?Z' Date Issued_ .. C_�/11: �l Area jys <br /> Grout Inspection BDate V2710 Final Inspection By Date <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 /> 350 1 '9"r /8377 elv7z? 0 - 0 5 R o^ -33 wog <br /> C-57 WC -WAVER C-57 Letter of Authorization to sign P rmit Encroachment doc 8/29/02 <br /> I <br />