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WELL . : RMIT APPLICATION FG - Al SITE <br /> EF LD SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> JUN 1 0 2003 304 E . Weber, Third Floor, Stockton , CA. , 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> pplimlion 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 /> )aquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ^� pp l , nn _ '/ ` � �r �'1.�./ Assessors 12 UC 3 <br /> ELL Location ) I L � S, L � b{ 6SC (?' G Cross Street -I- v y City S1rti,�'G:'1 zip IS;l() � Parcel# 7J . <br /> ROPERTY Owner V[tyt � e �O I Address. � • Qe X 11 0 7 City a' j- Zip qSS- Ol Phone#s�9' tl <br /> -57 Contractorcarc �te, b , VD_5Address 3 cityzip Lic# Phone#SI(o`&2 - Ilb `j <br /> onsultant / Sub Cntr Jk -a- Gz , Address � 3 -I ���� City LT Lic# Phone# gZ04rY(o l- ICL10 <br /> NV : DL%1P'tt,,t A I <br /> IS Coordinates: X , Y., Township Range Section <br /> iORK TO BE PERFORMED: <br /> 'NEWWELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER`) - 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # N( w Lf I1 ) 03 0 OVER-BORE <br /> `,WELL #ItNT- � 0 PRESSURE GROUT <br /> )they. <br /> Grout Specifications: <br /> OMMENTS ' r� Cf cacV�v�2 n 'r" PuM t Qm4A 4,ec F'r� <br /> (PE OF WELL. INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ' MONITORING HOLLOW STEM DIA. OF BOREHOLErr MULTIPLE CASINGS?;MULTI-LEVEL? 0 WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> AIR SPARGE / Ozone 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30 ') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ` <br /> CONDUCTOR CA ING PROPOSED?. ( if YES, list specifications here): <br /> ;OM+M&III;���`fff)TS: Cre4- Vesk b. • '� S'�"U(X. L - Vt I rGA , �Cf: n - i..ve l � r\ SNc II WK (Q \C. n <br /> � tECX O`1 A �.il � 00� czn, �rAc-yv�il tie �er 1.. •}z�l. <br /> NOTE : OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS . <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. + m <br /> w� <br /> hereby certify t at I have prepared this application and that the work will be done in accordance with San Joaquin r <br /> ounty O c , Rule and ulations, and all applicable California^^ tate Law�yrf'�s. rT� <br /> gnedx Title/Company {'t1IR11C Yll GPX)(, 11J( i-e \ MzNT+-c.. , ., <br /> rint Na �yNkSx:)Oer P1 Date 10 ):JAC x003 C=l <br /> DEPARTMENT USE ONLY <br /> ; ITE MAP IN UNIT IV FILE, ADDRESS : 3147 SOV{]n El Dorado 6 + Yr 4F+ <br /> VORK PLAN DATED : Apr; [ 9 2 oc z d p <br /> ,pplication Accepted By • "I' CL G r � Date Issued r I u 7 2003 L.Area 1451 <br /> 3rout Inspection Byyq,� /VCn.... Date O Final Inspection By n.�no�n Date <br /> )estruction Inspection By Date <br /> :OMMENTSI CONDITIONS: MWMg ' 12' . <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br /> 350 I 89. o 8 9. oo 00 3 47 5 <br /> -57_ WC.-WAIVER. C- 57 Letter of Authorization to sign permit_ Encroachment doc_ 8/ 29/02 <br />