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V EF) WE _. ��NIIT ,4PPLICATION F"M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> JUN 19 2003 'ENVIRONMENTAL'HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor,.Stockton, CA., 95202. _ , <br /> PERMIT/SERVICES (209) 458-3449 <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and toeStandards of SanJoaquin C my Environmental Health Department. <br /> } NOT,- <br /> KF T T)Ft"AN N G KETT lt+"fA r S Assessor's I <br /> WELL Location- I ypO,T. CA Cross Street AWM L /VL City L'toi T zip 9 �'IoZ Parcel# <br /> a Kt�} FMAn/ <br /> T£ G Address lin 1 liy Ciry L a D f T�pCIS� <br /> PROPERTY Owner VL Phon " °v* y-3x33. <br /> C-37 Contractor_ c�QQOF +</It{f �r}� Address r NJe _.Cnit�y CnADavA Zip Lic#7I75/4 Phan 106.5s <br /> Consultant/Sub Cntr 1 T• •F Address 937 5419 W 1�"Ci cST (y � b <br /> (08 e 2 Z 7 Phone# OQ y /00 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) [] DESTRUCTION(choose type below) <br /> o SOIL BORING# o OVER-BORE <br /> WELL# W' W- __ PRESSURE GROUT <br /> *Other: Grout Specifications: P- ATI-9n, ,Q "oC <br /> COMMENTS ' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS i <br /> MONITORING (HOLLOW STEM DIA.OF BOREHOLE g�� MULTIPLE CASINGS?]]MULTI-LEVEL?X WELL CASING DIA: <br /> 1]EXTRACTION 'j]AIR HAMMER/DRfVEN CASING THICKNESS S� tl v,C TYPE OF CASING: Q STEEL VC a OTHER: <br /> frlw•b — 9' <br /> a VAPOR MUD ROTARY DEPTH OF GROUT SEAL MI&-7 T$' TREMIE TYPE- SE USE ANGERS 0 HOSE <br /> p AIR SPARGE/Ozone Q PUSH POINT GROUT SEAL PUMPED: )]Yes � U F <br /> o (NOTE: MAXIMREE-F L DEPTH IS 30') <br /> a SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: 'ot` IAr,jD -r 1 fr <br /> I]OTHER: ll OTHER APPROX.BORING DEPTH nRtr,,.7: 9rs d BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? if YES,list specifications here): <br /> *COMMENTS: SQL^ v� V . Z o 6 <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, R les and Regulations, and all applicable Californi DState Laws. <br /> Signed x Title/Company ►f 4� CT 6�a,/ 6T F . <br /> Print NameZ7�-' J. C Y fid Date 06 — I$ - Oa <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Fay �-d�C Date Issued !Z O� Area <br /> Grout Inspection By ��. Date yt 0 Final Inspection By Date <br /> Destruction Inspection By Date t I <br /> COMMENTS 1 CONDITIONS: f <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �SOtIf ZO—I 9/ a 5,+e Do3 �3 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment clot 8/29/02 <br />