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WELePERMIT APPLICATION 64RM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> WELL Location ' '�''✓�� Cross Street �$M City Zip�� 7B-Parrcc�elldAssessors <br /> PROPERTY Owner 6GVI to �r� Address B Jul City t'.C Zip PtSbne#03'S <br /> C-57 Contractor ao (,l�Q/v L ( 4�ddress PV 33��P `l �f City (0 QLS-6ip�` _571Uc#'7'0a-'7'061Phone <br /> Consultant!Sub Cntr •�-7 r�' `J _Addrej - /L� / Z City- &ic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ,815ESTRUCTION(choose type below) <br /> Q SOIL BORING# ;OVER-BORE <br /> Q WELL# b:frRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ? <br /> 0 rnoi <br /> ,'MONITORING �OLLOW STEM DIA.OF BOREHOLE D ULTIPLE CASINGS? MULTI-LEVEL? WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS .$/ft- TYPE OF CASING: []STEEL fffVC Q OTHER: <br /> Q�APOR Q MUD ROTARY DEPTH OF GROU EAt~5'O - 3 t TREMIE TYPE TO BE USED: AUGERS Q HOSE <br /> AIR SPARGE/Ozone Q PUSH POINT GROUT SEAL PUMPED: ArYes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: '0&4 or,., 4 <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH IPP *''Q Z-90LTED TRAFFIC BOX or Q STOVE PIPE <br /> CON UCTOR CASIN PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: ov" m Ij f w Afto <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,-Rules and Regulations, and all applicable California State Laws. �( <br /> Signed xy" '�'"�.� yi-11 Title/Company h (9 E- �9 QJ <br /> 9 �� }�_ <br /> Print Name w alt [.�+� t 7�[� Date /,R o?/'Z2- <br /> DEPARTMENT <br /> 2DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: a,37 Z) .5` <br /> Application Accepted By t ` Date Issued ?� Area <br /> Grout Inspection By Date 1,24-01b Y Final Inspection By Date 3 <br /> Destruction Inspection By t � Date 1 .3 y <br /> COMMENTS/CONDITIONS: 3 �- d a�' v kl t V W 2 W 1 M ul 2 <br /> AQCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMI ED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 4 !77 2 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment docT 8/29/02 <br />