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r <br /> WEL;"PERMIT APPLICATION FOF,...., SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <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 Joaquin County <br /> Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Ili &FW i':ILer y ,,,,L_ p /e _ Assessor's <br /> WELL Location_ rrn�n,,t� �n� � Cross Street u�u�L�t Cit Zi ]'�zc Parcel#j gq-tel)'"�t' <br /> PROPERTY Owner��KCS 1 lEfaj Address 2�3d pW��{��4(Tf/, 1 I City Mf&,� Zi -T 0 Phone# / I" <br /> C-57 Contractor �R`p- Addressq,33 ! t4A"> F-&It] City { ZipjLu�Lic# Phone �Lq) 4 7-1 W 1, <br /> Consultant I Sub Contractor A-Cr . e Address$ .SSI At-..,0,44e Cit�,y�j lel LiC# Phone# w�I daO <br /> GIS Coordinates:X Y Township Range Section <br /> ORK TO BE PE MED: <br /> NEW WELL I RIN (CPT,Q OPR E,HYDROP CH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> L BORING# 0 OVER-BORE <br /> WELL# H PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> H MONITORING H HOLLOW STEM DIA.OF BOREHOLE1 zs MULTIPLE CASINGS?0 YES KNO WELL CASING DIA: <br /> 0 EXTRACTION H AIR HAMMERIDRIVEN CASING THICKNESS �& �TYPE OF CASING: H STEEL H PVC []OTHER: <br /> H VAPOR H MUD ROTARY DEPTH OF GROUT SEALrrrA TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> H AIR SPARGE 'PUSH POINT GROUT SEAL PUMPED: 1Yre�s 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING H HAND AUGER GROUT SPECIFICATIONS:: ?,It-rj k0 -i/+ fi --r <br /> H OTHER: Il OTHER APPROX.BORING DEPTH lD r 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> `/C CONDUCTOR CASING PROPOSED?�(if YES,list specification( here): <br /> 'COMMENTS: ,� 04l,k L (&-l�� Td l of FCL--bi r*7 �t4 I.t,AELIE�A-,,,P1-E.] RIO e&%1&S <br /> rhe <br /> NOTE: OFFSITE BORINGS RE DIRE 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 prepay d this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> Rules and Regul tions an a licable California State Laws. C�+� r <br /> Signed x Title/Company S-MrrF L D�(�I/1�e7Lf4l�L6�� CrEyfGwGt/IRC [lI t��µZtlL <br /> Print Name /gulf - DateL3{I('rI, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By_ Date Issued '1� F J 0 Area <br /> /- <br /> i <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY lD�A.TE PERMIT!SERVICE REQUEST# INVOICE <br /> D 1 7 A-0 I �'11 y �`` Z SR# a2�I <br /> C-57T WC -WAIVER C-57 Letter of Authorization,to sign permit_Encroachment doc_ 1/25/02 <br />