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ti ELLIERMIT APPLICATION FORM SITE <br /> SAN JoAQU1N COUNTY MITIGATIONIRONMENTAL HEALTH DEPARTMENT (EHO) UNIT IV <br /> JAN 2 4 Zoo�04 E. Weber, Third Floor, Stockton, CA., 95202 <br /> `JNIIVIRONMENT HEALTFLI (209) 468-3449 <br /> ON_REFUNDABLEPERMITEXPIMI)XARFROMDATEISSUED <br /> Appllcatlon'u^h.1.11,made tb`5`aM 9t u�I County for a permit to eonCttuet and1w install the work desaibsd. This application i5 made In Compliance with San <br /> Joaquin County Development Title,Chaptor 131115.3 and the Standards of San Joaquln County Environmental Henith Department <br /> WELL L.oearron //;Z Sap S, Jar l-"II Sf Cross Street AMA,wIIC pr, Clry � .di Yip �QR Ifo Parcae#ors x /� <br /> �,f n 1 <br /> PROPERTY Owner. y 0(' Lnp[_Atldcess /3_�� �. ✓ o-M Lh city--L-o4, Zip q2`I'0 Phone# <br /> c37 contmCor GrP.J°)o� F.�r117 Address 9.�G �r,�..�c ✓laf. Gry lvl.r F;rt, Zp gyr'rjt;tz Sl��7 Phones!/9)sJ 313-s-ace <br /> Cansult7nt/Sub CntrZ Aadress�.fL te«,n.orr�-1 C;y e/[Cty .ar. av� Lic7F F4pne#(i'2s���8-f1 GU <br /> GLS Coordinates:X.Y .Township Rango Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WPLL 1 BORING (CPT,GEOPROM,HYDROPU NCH,HAND AUGER,OTHER') a DESTRUCTION (clwose type below) <br /> 1 SOn-BORING# CP l- ) – 15 <br /> E WELL# S - S 11 PRFSOVERUREW DIAMETER <br /> 0"OUtcr � �PRESSURE GROUT <br /> COMMENTS: SA - q- An SA - 1 Aelbt.lr4�,pt •t 1/.2.2/p UT SPECIFICATIONS <br /> TYPE OE WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT)ONS <br /> ■MONITORING j HOLLOW STEM DIA OF BOREHOLE2 jN 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: /y/1 <br /> U EXTRACTION 0 AIR HAMMERIDRP/EN CASING THICKNESS iNA4 TYPE OF CASING- U STEEL U PVC 0 OTHER N/A <br /> 0 VAPOR n MUD ROTARY OF PTH OF GROUT SEAL-74 TREMIE TYPE TO BE USED: n AUGER@ Y HOSE <br /> UAIR SPARGE]OZONE IPUSH POINT(GP crCPT)GROUT SEAL PUMPED; 0Yes UNo (NOTE_ MAXIM UMFREE-FALL DEPTH IS30') <br /> $SOIL BORING a HAND AUGER GROUT SPECIFICATIONS ;V"-y <br /> U OTHER:-n OTHER APPROX.BORING DEPTH_ 70 P4� 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_ Ne (If YES,list spocifcations In comment section) <br /> roMMENTSt ZPr—i .,.. 1./ W;It 1b <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AG EEMENT OR ENCR ACHMENT 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 <br /> County Ordinances, Rules and Regulatio d all applicable California State Laws, <br /> Signed TitlelCampany �/� ��L( /)//U LT7 1 r� <br /> Print Name Date ZS. I D 7--- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> ��// ogd <br /> nppfication Accepted Date Issued_l�rY�b L- Arad- <br /> 3rout Inspoctlon By Date I Z 12, 0 mal Inspection By Date <br /> ')estruclion Inspection By Date - <br /> -OMMENTS I CONDMONS_ <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> 2PL±SF;INFO AMOUNT REMITTED CHECK# RECD BY DATE_ PERMIrl SERVICE REQUEST# INVOICE <br /> C-57— WC,---WAIVER C-57 Letter of Authorization to sign P"mit_Encroachment doc,___ 9/30/02 <br />