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nnnu <br /> WELAERMIT APPLICATION FM FI1-E VUf i <br /> FQj SAN JOAQUIN COUNTY MITIGATION <br /> r��15 JUN 19 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENI HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 # 11 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^MI1Ip L <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 compliancevnth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standardsf San Joaquip County Environmental Health Department. <br /> I [� IFrI. £ p Assessor's / <br /> WELL Location L4 �AGi(`{L / WoJ A Cross Street U/ C 7 City .S/OCKTOnZip /5�0 Parcel# id� V <br /> PROPERTYOwner JtR({-1 $4L(0 Address gyps 1' JOL. City s�9t-k%9✓1 Zip 76a7L9 <br /> Phone# 5 Yhf 553(-1C-57 Contractor 5C 0E_ .d ,V1, l Address ity .pc� Zip?57gLLic#7175/0 Phon 9f J. 63C— 69 <br /> Consultant/Sub Cntr /7 .��. Address )� 7 <br /> _544 V-Act City STocl (I-Lic#6 Qo .? Phonek" 7 b 7/o a 6 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'ANEW WELL/BORING(CPT, GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> // 11 0 SOIL BORING#�_ a OVER-BORE <br /> WELL# /✓J 111-/_ M t'V-j_ 0 PRESSURE GROUT <br /> `Other. I Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ` <br /> ,MONITORING �OOLLOW STEM DIA OF BOREHOLE g /r MULTIPLE CASINGS? ULTI-LEVEL?a WELL CASING D <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS sw oDv1 t TYPE OF CASI� IA:O STEEL PVC O OTHER: <br /> 1]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S�THEME TYPE TO BE USED: p AUGERS *OSE <br /> p AIR SPARGE/Ozone p PUSH POINT GROUT SEAL PUMPED:-AkY0 No (NOTE: MAXIMUM.ff�E-E-FALL DEPTH IS 301) <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:( T/.9 cyQ J;r P - <br /> Q OTHER: fl OTHER /� /n1 APPROX.BORING DEPTH �� OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> c.JL� QpveV ��RKTORyS�I`NJG PROPQSED? (if YES, tsptionon3 <br /> `COMMENTS: /I-/// �TE ,Af.LO-t` <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 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or mantes, Rules and Regulations, and all applicable California to Laws. <br /> Signed x T <br /> / <br /> tle/Company RQi G % �/fl [Cr 1 �- <br /> Print Name l l+y.O 7*/4 r J wQ� � Date Jb'' l / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� f ` 'LZO P� <br /> WORK PLAN DATED: -!> <br /> Application Accepted By Date Issued o J Area 00 <br /> Grout Inspection By Date Final Inspecbon By Ca.0 v <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REVD BY DATE PERMIT SERVICE REQUEST# INVOICE - <br /> 4g — 2990 6- -�f2 00 g <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ 8/29/02 <br />