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SITE MITIGATION UNIT IV <br /> WELL PERMIT APPLICATION <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT3I=PIM4 2004 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 ENVi ONiO'EN1 HEALTH <br /> (209) 468-3449 PEf?Mi f/Sr-1?',gCES <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 Joaquin <br /> County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assesso <br /> �L,rs�s Saeef C� S�A�City L.0 zip Parcel# (1-Oq-SI <br /> WELL Location �7">YYi' 11I HV wAII ( J:0-0&,,s �5 <br /> PROPERTY Owner W0bD IBR'IX E.��A) .1%Address /o>1 T' �Gn}'_I7J_PJ��CiIY /1 T� f ZiP Phone# G' <br /> c#� I ZPhone# 2 <br /> CS7Contractor sr`' ��UI� Address 3(.5 (.1Jt�olU/}Y1i( C'i1y ,�tiP --t- -+�-"— <br /> Consultant l Sub Cntr taa:l l `GnL. Address 17.7N 3 pap <br /> 615 Coordinates:X <br /> y ,Township Range Section <br /> WORK TO BE PERFORMED: - <br /> EW WELL/ BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) B DESTRUCTION (choose type below) <br /> OIL BORING# PJ <br /> it B OVER-BORE. DIAMETER <br /> � n L B PRESSURE GROUT <br /> B,WELL# <br /> B*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYP"F WELL <br /> INS LATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING - <br /> HOLLOW STEM DIA.OF BOREHOLE L( B MULTIPLE CASINGS B MULTI-LEVELS WELL CASING DIA: Z rf <br /> n EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: B STEEL [ BOTHER: <br /> n VAPOR B MUD ROTARY DEPTH OF GROUT SEALS / TREMIE TYPE TO BE USED: B AUGERS OSE d <br /> B AIR SPARGE/OZONE B PUSH POINT(GP or CPT)GROUT SEAL PUMPED: es n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> B SOIL BORING B HAND AUGER GROUT SPECIFICATIONS <br /> n OTHER: B OTHER APPROX.BORING DEPTH �� r B BOLTED TRAFFIC BOX or TOVE PIPE <br /> CONDUCTOR CASING PROPOSED L) _(if YES,list specifications in comment section) <br /> COMMENTS: <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 /> Ordinance , les�p ulation and an Il applicable California State Laws. <br /> Signed z / (n� \ TNe/Company a /J <br /> Print Name %c.-ii it i !�I F�/l,1 l�//.' C-� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date Issued cl/ D 7" Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: FA <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sigh p rmit_Encroachment doc_ 9/30/02 <br />