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I <br /> 2 �r, WELL.'ERMIT APPLICATION FOAM SITE <br /> MITIGATION. <br /> SAN JOAQUIN COU TY UNIT IV <br /> JUN 19 2003 ENVIRONMENTAL HEALTH DE ARTMENT (EHD) <br /> ENVIt�DNME 1 HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICE"; (209) 468-344 <br /> NON-REFUNDABLE PERMIT EXPIRES 4 YE LR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct anti/or install th work described. This application is made in compliance with San <br /> Joaquin County r--i—mcant Titin r'ha f+ o-a 1-1 F 3 anH.the Standards�ppf San Joaquin unty Environmental Health Department. <br /> )<FN� Assessor's i <br /> WELL Location DFS•}irrAru `-'a D�•L,++�1K Cross Street � ity fl D► Zip <br /> 9-5c?yd Parcei# <br /> Norr�ap< 1300 E1�gdnA+v zpNL Df <br /> PROPERTY Owner Cat'fX� Address a)1 7+ City MO; zpq 5'-7 y J Phon 2m9 'boon <br /> C-57ContractorCflSS090 . DI'd1l'19 Address 3$32- rt3ADa.tt Zip Lic# 7i79A!Phon 4! 3 -&0 <br /> Consultant/Sub Cntr ►^�.�i, Address83 7 S AD Cityj_� - Lic# ty 22 7 Phone# Z9G1< Yb 7''/Oce 6 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER" DESTRUCTION(choose type below) <br /> SOIL BORING#- a OVER-BORE <br /> ELL# Ah LII a PRESSURE GROUT <br /> "Other: Grout Spec fications: <br /> COMMENTS !M L✓ +*3D 1 W• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIO 5 <br /> MONITORING IOLLOW STEIN DIA. OF BOREHOLE_ ^MU @ LE CASINGS?©MULTI-LEVEL? WELL CASING DIA.� <br /> o EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS 5Z- e4 t TYPE OF CASING: []STEEL *VC O OTHER: <br /> j]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE'USED: )0UGERS 11 HOSE <br /> l7 AIR SPARGE/Ozone D PUSH POINT GROUT SEAL PUMPED: q Ye o (NOTE: MAXIMUM��FREE-FALL DEPTH IS 30') <br /> []-SOIL BORING ©HAND AUGER GROUT SPECIFICATIONS: iO 7' C +r— <br /> a OTHER: f]OTHER APPROX.BORING DEPTH �Zo'O TED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOS D? (if YES,list specifications here): <br /> 'COMMENTS: S o zov@� o en Vim^+ � P O 6A <br /> ro <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 /> I hereby certify that I have prepared this application and that the wok will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California Ermte Laws. <br /> Signed x 141" Title/Compo y G-r to �^ + <br /> Print Name C V ej Date L <br /> DEPARTMENT USE ONLY <br /> } <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I' <br /> WORK PLAN DATED: l / n <br /> Application Accepted 8y Da lssued�/13Ib'7 Area ed r- <br /> Grout Inspection By Date Final Ins ection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' 0ATE PERMIT!SERVICE REQUEST# INVOICE <br /> SDt <br /> 'Fill q - 2- Go S a37 �BS <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />