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� try � <br /> WELL PERMIT APPLICATION FIM 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 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 Environmental Health Department. <br /> �� Ave Assessor's ! <br /> WELL Location `l 4� ��1!<ti�. /4Vk-p o s StreetK,l- 05 s}, /ity STn�K=nn Zp 95ZOf Parcel# <br /> VAN �� P. �n+�C�f��J P Phone# 9 <br /> PROPERTY Owner DA o �wA-U-Address i9. Qo City STs&I'74n -Zip�JSZoI 2�y �Yz / 1 <br /> C <br /> c )'r0e Ci a�Zip`��yZ Lld#71 TSYp Phone yob '/!�y <br /> C-57 Contractor C Address 632.. QM C City coA,*C.,_ <br /> Consultant l Sub CntrcI kQ IA.ldress 03_7S)44--1 R�City ST9ch Lic# o Z Phone#2�4 Y b 7 1 0b <br /> GIS Coordinates:X Y ,Township Range Section <br /> 1 <br /> WORK TO BE PERFORMED: <br /> )IEW WELL 1 BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# Mw-13 ,_ Q PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS Rl-P1 en,on+ of ►v£I -13 ' SQL Ar-, 2L Ella Z <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ';AONITORING HOLLOW STEM DIA.OF BOREHOLE O 1j MULTIPLE CASINGS?MULTI-LEVEL?a WELL CASING DIA: ! <br /> r` cdj <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC pTHER: <br /> fl VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE 1 ozone 0 PUSH POINT GROUT SEAL PUMPED:*es 0 No (NOTE: MAXIMUM FREEC ALLn'DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: ^ rr <br /> �„ J v;rJi o+1 tz <br /> 0 OTHER._0 <br /> OTHi R APPROX.BORING DEPTHQ ^I. JkBOLTED TRAFFIC 80X or 0 STOVE PIPJ <br /> CONDUCTOR CASING PROPOSED? _(if YES,list specifications here): <br /> *COMMENTS: <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 Californi ate Laws. ` <br /> - <br /> Signed x TidelCompany £ <br /> "A Date r <br /> Print Name IF <br /> DEPARTMENT USE ONLY <br /> f <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: I <br /> �L �✓ Date assued �� AEea r <br /> 06 <br /> Application Accepted By i Ob to <br /> Date Fina inspection By L <br /> Grout Inspection By ! <br /> Destruction Inspection By Date <br /> f <br /> COMMENTS 1 CONDITIONS: . <br /> 7EACCOUNTINIG2 ONLY: AID# <br /> FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATEPERMi71SERVICEREQUEST# INVOICE <br /> ='� : � spa , <br /> C-57 WCWAIVER C-57 letter of Authorization to sign permit Encroachment doc g/29/02 <br /> C <br />