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REC 1 _ WELOERMIT APPLICATION �M SITE <br /> SAN JOAQUIN COUNTY <br /> .IAN 2 0 2301 ENVIRONMENTAL HEALTH DEPARTMENT(EHD) MITIGATION <br /> ENVIRON <br /> 304 E. Weber Third Floor Stockton, CA., 95202 UNIT IV <br /> PERMIT/SE-h", ,' -j SE � i R (209) 468-3449 <br /> � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora 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 /> WELL Location C k-N Pte;-Q;c QL,"U5 Cross Street 5O cr ue-• Ci S-—k4a-1 �'/'�A pare#gym A11A <br /> �e- '�,' ,� tY Zip <br /> PROPERTY Owne n f�5 �r�rr,,//�'s Addressil go- Oa R(4611-540"-City-9.z o -rx Zip�2y6 Phone4C S- 19c <br /> C-57 Contractor�reqs �.-• II i n9 Address s e- RId CI IyZ44,4,kt.?-Zip`-? 553 Lic# S(C Phonek <br /> Consultant/Sub CnV C-a*nbr, Address�� li". k ny 5-r�.,C+ Ci Sc�rp,,,,o RG <br /> H Lic# Phonek`� 9S5-tiEso <br /> GIS Coordinates:X /V 1/4 ,Y_ �/A ,Township N +� Range N 'Q Section A114 <br /> WORK TO BE PERFORMED: <br /> >RNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') -ODESTRUCTION (choose type below) <br /> SOIL BORING# DOVER-BORE. DIAMETER <br /> ,WELLk M.r-u - l3 aPRESSURE GROUT <br /> 'Other <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -&MONITORING ^HOLLOW STEM DIA.OF BOREHOLE I o" D MULTIPLE CASINGS ()MULTI-LEVEL W ELL CASING DIA: H r/ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSSc k-®o TYPE OF CASING: 0 STEEL ;RPVC D OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL �O/ -TREMIE TYPE TO BE USED: GAUGERS Q HOSE <br /> (1 AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Ayes 0 1No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS % -f bi of a+, o I x/71 <br /> 1]OTHER: n OTHER APPROX.BORING DEPTH g0 _mob-wOLTED TRAFFIC BOX or [ISTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: O Gaor o <br /> NOTE: OFFSITE B RINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinance(�5, ,(�g ''les and Regulations, and all applicable California State Laws. <br /> Signed x_� uN��i r1oIN/'!r Title/Companyn <br /> Print Name Y �/ ewner Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADPRSS: (n ( � / �_A c. (2/tA c 5/arp <br /> WORK PLAN DATED: /O 1 3�O 3 <br /> Application Accepted By N Date Issued 1 /2 2 jC'&/ Area Z <br /> Grout Inspection By (i1�.tnnc�c D " <br /> ate L O Final Inspection Bye- /( t ag Date -L O <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST If INVOICE <br /> 3507( { `6 •oo 1453 / ( z o sR# 36 � 33 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />