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SITE MITIGATION UNIT IV <br /> WELL PERMIT APPLICATION FORM <br /> REC t-'NE10t SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EF'D) <br /> NOV - S 2005 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> ENVIRONMENT HEALTH <br /> (209) 468-3449 <br /> UF�MITI6ERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is re y made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin <br /> County Development TN//e11,Chapter 9-1115.3 and ttg Standafdso of Joaquin County Environmental Health Department. <br /> I13�J 4 G I�, l�l()A�+tL 1 1C1roosss Streetwal2 KSDAI E C L _ Asserce s <br /> WELL Location city CD1 Zip96240 ParcepFAP <br /> AfO)7-0j-5 <br /> PROPERTY OwneMjpo `'jQZLnL�P %a-r _EWddress(-3'j E. LOcKEFn tLT)�'5TCity�L,d'D t Zip IT Phone# ,333-(( i <br /> L J1�2_� S/ZZGB <br /> C-57 ContractorSPGL�fLiM Address23GS Wt6WAN�J City Zip ic# Phone# 6S-g7/Z <br /> Consultant/Sub Cntrl`Ll/iLL E►J 6s. Address)2.153. nnp( L.A >rty LeD 1 Lic#1q 572. Phone# 36B- '[53 I <br /> GIS Coordinates:X Y ,Township Range Section <br /> WOR TO BE PERFORMED: <br /> W WELL/ BORING (CPIT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a DESTRUCTION (choose type below) <br /> a SOIL BORING# 13I i tttt I 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other / ROUT SPECIFICATIONS <br /> COMMENTS: SnIC. 54lvl P t= _ -rggAJ G20u1 �AcA::� el LC-- <br /> TYPE OF WELLINST LLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> 0 AI SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 6 M I_ <br /> a OTHER:_D OTHER APPROX.BORING DEPTH 4 O ' a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> C y CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: X ,L n k LLA <br /> NOTE: OFFSITE BORINGS 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 County <br /> Ordinanc , Idles a latio , and all applicable California State Laws. <br /> r/ / <br /> Signed x Title/Company?/ /X ,Lt— FA-26 /A 1 EES <br /> Pnnt Name L Date I I-P, - O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATE/D:: -p a <br /> Application Accepted By''1h1 -YI�M.o>'/l Date Issued /[�`I/0 Area <br /> Grout Inspection By !� � Date II . I I Final Inspection By Date <br /> Destruction Inspection By Date l 1 <br /> COMMENTS I CONDITIONS: C ✓IQ+v auk (..LrLsQ_ 25.i.....y - CGlt.tlt Qct.✓t 2 r-t4� <br /> ACCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMOUNT REMnTED CHECK# REC'O BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> dgot 85' 84 -7(3 !tK /t o� SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />