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VVELLK ERMIT APPLICATION FG-.,M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT I!! <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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 /> II��rr Assessor's <br /> NEL.L Location I oaG SI <br /> odik nth G., Cross Street oy i Se Ave city LA-Krolp Zrp -5_9 33O Parcel# <br /> ?ROPERTY Owner A)0.� cnck o g Address yZZ rJ £. 144MMGr City. 5Y Zip 9SaI Z Phone#570'a258 <br /> -57 Contractor[rlvirO�rObC Address 3315 F. M,r..lof`+0.#I\9City A^4kt;m Zip 92801� Lic#W-)-U-7Phone# y6- 100 <br /> ,( c G� (� C-,5� L <br /> consultant I Sub Gntr ['t ! E Address a 3� S�a` � _bt City ST r` Lic# (08022 7 Phone# I�O7' 00(0 <br /> GIS Coordinates:X Y Township Range Section <br /> NORK TO BE PERFORMED: <br /> ANEW WELL!BORING PT,GEOPROBE,HYDROPUNCH;HAND-AUGER,OTHER-) ❑DESTRUCTION (choose type bela�r) <br /> #SOIL BORING#S Q�- �'lto-ob S Q'9 0 OVER-BORE <br /> WELL# p PRESSURE GROUT <br /> `Other. Grout Specifications: . <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> q MONITORING Q HOLLOW STEM DIA_OF BOREHOLE 1 ��S MULTIPLE CASINGS? MULTI-LEVEL?Q WELL CASING DIA: <br /> EXTRACTION NIR HAMMER/DRIVEN CASING THICKNESS-- �TYPE OF CASING: 1]STEEL 0 PVC a OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL / lJ TREMIE TYPE TO BE USED: []AUGERS Q HOSE <br /> p AIR SPARGE I OzanePUSH POINT GROUT SEAL PUMPED: p Ye p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> K,SOILBORING aHAND AUGER GROUT SPECIFICATIONS: -to S.,�Fo.cG <br /> Q OTHER: ❑OTHER APPROX.BORING DEPTH a.5 Vtct []BOLTED TRAFFIC BOX or i]STOVE PIPE <br /> CONDUCTOR CASING PROPOSEP? (if YES,list specifications ere): <br /> `COMMENTS ~ I <br /> NOTE: OFFSITEORINGS REQUIRE ACCES OR ENCR. ACHMFNT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby,certify at I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O n ce ul and egulations, and all applicable California State Laws. I� <br /> Signed x Title/CompanyI JQn Fob pA ( � - <br /> Print Name r i S-4 e r < <r- Date O 0 3 <br /> DEPARTMENT USE ONLY <br /> /�7 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /a l <br /> WORK PLAN DATED: — Q <br /> Application Accepted By <br /> Date Issued U r� Area �� <br /> Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDf110NS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST t# INVOICE <br /> j 4)&0 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit &111'F'Encroochment doc 8/29/02 - <br /> - <br />