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WELssPERMIT APP'LIQ;MON FO(kmd SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 FIL x ' -- <br /> tv i, A <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 County <br /> Development Title,Chapter 9--1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's <br /> WELL Location Og Cross Street <br /> er� pQe ir" iiity Zip Parcel# L <br /> PROPERTY Owner i Address��t/ kvc6--1 ` t -5 Zip 7` /,� Phone# <br /> C-57 Contractor✓" Address-�/�3 �/v L^�C,itY�&'tc"�`Z Zips✓' AU-67 �� hone#% -7�> <br /> Consultant/Sub Contractor <br /> C Address 7 S� Lie# Phone# 1� � <br /> Coordinates: <br /> X <br /> Y Township Range—Section- <br /> GIS <br /> angeSectionGIS <br /> W RK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> j�WEW WELL/BORING(CPT, <br /> CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a OVER-BORE <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> # <br /> 'Other: WELL Grout Specifications: <br /> COMMENTS: 1 <br /> CONSTRUCTION SPECIFICATIONS �jN /� !1 <br /> TYP F WELL INSTALLATION TYPE <br /> ONITORING LLOW STEM DIA.OF BOREHOLE E" > / MULTIPLE CASINGS?Q YES [}' O WELL CASING DIA: <br /> ,1XTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING�STEEL PVC OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /1j FeC-T—TREMIE TYPE TO BE USED: ff<UGERS Q HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes kno (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: �n�2+�/ <br /> p OTHER: p OTHER APPROX.BORING DEPTH SO � LTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <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 County Ordinances, <br /> Rules and <br /> /Regulations,and all applicable California State Laws. J���! , II(� <br /> Signed x LN�(. J � Title/Company <br /> �� Date /02 v2 <br /> =rintName W 1 J t "'fit^ Til DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: z �9 <br /> WORK PLAN DATED: Z II5i5D l <br /> Date Issued 7/� Z Area <br /> Application Accepted By i -' <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S1 0 � 1 /L z SR# P 5 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc_ 1/25/02 <br />