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WELL 1%,AMIT APPLICATION Fk,6� 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 1 11 <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 Erivironm Intal Health Department <br /> WELL Location r I – Cross Street City Zip Pa Assessor's <br /> PROPERTY Owner Address �D��)\4 [_.t ity /bli�Z1P 0 !Phone# <br /> C-57Ccntractor P— N14dress .6, -� S{�o� el _Cf AZi 21�' i hone# 7 1d(�� <br /> , iConsultant I Sub Cntr Address City Lic# Phone# <br /> 17 ' <br /> GIS Coordinates:X Y Township ik Range__SeQicn <br /> 1 If r I <br /> WORK TO BE PERFORMED.- <br /> I <br /> EW WELL/BORING(CPT, E—P HYDROPUNCH;HANL-ALIGER,OTHER*) !{ I 13 DESTRUCTION(choose type below) <br /> Q SOIL BORING# []OVER-BORE <br /> [t WELL# 7 Q PRESSURE GROUT' <br /> "Other Grout Specifications <br /> : i- <br /> COMMENTS I� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> s []MONITORING aHOLLOW STEM DIA.OF BOREHOLE �hdtMULTIPLE CASINGS?QMO--n-LEVEL?a WELL CASING DIA: <br /> p EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS-&AZ �TYP }OF CASING: [I STEEL a PVC d OTHER: ` <br /> "VAPOR (I MUD ROTARY DEPTH OF GROUT SEAL ✓� li,TREMIE TYPE TO BE USED: GERS OSE <br /> {AIR SPARGE/OzOftO CISH POINT GROUT"SEAL PUMPED: Q Yes (NO 'E:IMAXIMUM FREE-FAL DEPTH IS 30°) � <br /> P45611-BORING a NAND AUGER GROUP SPECIFICATIONS: <br /> I]OTHER: _ f]OTHER APPROX.BORING DEPTH t5D a 1BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOq CASING P OPED? f (if.YES,list specifications here): <br /> 'COMMENTS: p <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE4FOR 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 <br /> County Ordina ces, Rule nd Regulations, and all applicable California SSttaat/e�Laws. /J f� <br /> 9 �� Title/company K �(XF/ T� r <br /> Signed x <br /> Print Name <br /> (Date <br /> DEPARTMENT'USE ONLY <br /> i SITE MAP IN UNIT IV FILE, ADDRESS: Z $`r Sg u+ a 1'g, —Ri Ovl <br /> WORK PLAN DATED: V, l10 ff2L(� <br /> I <br /> Application Accepted By Date Issued # Lf Area <br /> Grout Inspection By Date ' Final Inspection By ik Date I <br /> Destruction inspection By Date �r- ,a 11 , , <br /> COMMENTS/CONDITIONS: 4-� <br /> H <br /> -yz 66 <br /> y }} <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT R€MUTED CHECK# REC,D BY DATE 11 PERMIT/SERVICE REQUEST# INVOICE <br /> 350 <br /> 9g. 00 �� T` SR 003s 40j } <br />`` C-57^, WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc� 8/29/02 <br />