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WELAERMIT Apd*' KATION AM SITE y II <br /> T SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 appiicafion is made in compliance vdth San <br /> Joaquin County Devel pment Ti CChapter 9-111 3 and the Standards San Joaquin County Environmental Health Department <br /> 1, 71/ Assessor's <br /> WELL Location / Cross Stree City _Zip Parcel# <br /> PROPERTY Owner �t 1j (NO IaGK Toll Address �a�J N,EL 0bAli DP CityS%oc KTPFI Zip ySzV ZPnone# Le 937 <br /> u Fr0 �Ambtl <br /> C-57 Contracto<AK A4e. �Q Nr. Address o'�.� MEG C/ Cle City c8 RO Zp957yZLic#7/ ©Phone476435'/I6 <br /> Consultant I Sub Cntr ,G,� , AddresS-85— SHAW RD T %�� <br /> CiIYSLi�# <br /> AGbfzZ ) Phone <br /> GIS Coordinates:X ,Y _ ,Township Range Section <br /> W RK TO BE PERFORMED: G <br /> EW WELL/BORING(C,PT, GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER') / DESTRUCTION(choose type below) <br /> Q OIL BORING# p OVER-BORE <br /> /ELL# Hvw`/5rMW•i w`17rMw-($/lvt w-15 0PRESSURE GROUT <br /> •Other Grout Specifications.- <br /> COMMENTS <br /> pecifications:COMMENTS SF£, a4-.}gc.,140 CITE eF SjocK'ra.,, f;nCfoac�h.rwrrk fQ^�%jl- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �1ONITORING ,g HOLLOW STEM DIA.OF BOREHOLE SS rr MULTIPLE CASING ? ULTI-L.EVEL� WELL CASING DIA: <br /> \\ \ scn��l2 <br /> Q EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS__P ___TYPE OF CASI eEL (]PVC OTHER: TEFI o,j <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 U �'(- TREMIE TYPE TO BE USED: []AU ERS a HOSE <br /> o AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED:�1es p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> j)SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: Po A Jt r T E <br /> p OTHER: p OTHER APPROX.BORING DEPTH .t BOLTED TRAFFIC BOX or a STOVE PIPE <br /> �f CONDUCTOR CASING PROPOSED?_ 0 (if YES,list specifications here): <br /> *COMMENTS: ll r&ASE /�, /1F.Tir 7o WOAK P/AnJ da F1) 1/,4eArL Z ?n.'4 <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 <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. n G <br /> Signed x Title/Company <br /> Cr �O <br /> Print Name tm •7h1 Vf ('Vo/AA Date <br /> DEy�PARTM T USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: v a l <br /> WORK PLAN DATED: 'l <br /> Application Accepted By Date Issue Area © - <br /> GroutlnspectonBy Date Final Inspection - ✓J 3 j <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 Mw = la`IZ`t - to-Is 35 8l <br /> Encroachment doc 8/29/02 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ <br />