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WELL rERMIT APPLICATION MfM FILL <br /> SITE <br /> 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 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 /> •T HnrA4w^rY 1� Assessor's <br /> WELL Location 106 IM.TFN <br /> IoRTeN RJ- Cross StreetC'Apj:bL Ave• Ciry Lop/ Zip 95,74/2 Parcel# 055_- /6O.Z6 <br /> A '7 , E A1iUj g 778a <br /> PROPERTY Owner RNDy C.ArAK,a,n oAOiIL'� AddressPO. 13wx /o3b Ciry /RAc�r Zip 95378 Phone»ZQ <br /> ) 2r P A,,;A r ,o p 6 <br /> C-57 Contractor c ' li. Address✓npc OMEG �iKl2 Clty CnpmvA Zip95792 Lit#F 7/75/0 phone# 9/6 tO-�O– <br /> Consultant/SubCntr_ A .G.F_ . —Address S37 Sgiw Rd- city ! 7crnnl.Jc# 4D-?t>7 Phone# Z,w /I7-/4Q <br /> GIS Coordinates:X ,Y ,Township 3 N Range SE Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> WELL# Mw••7 MW–fs .. M W-9p O PRESSURE GROUT <br /> 'Other: t o - Grout Specifications:_ Toq-rLANO TPE f <br /> COMMENTS 51ES AQVRoteD WORK PAN,. 'DATEQ a3 Jj,14 -11 C, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I vMONITORING *OLLOW STEM DIA.OF BOREHOLE fi" MULTIPLE CASINGS?MULTI-LEVEL?0 WELL CASING DIA: <br /> 0 EXTRACTION //0AIR HAMMER/DRIVEN CASING THICKNESS-5 4CJ-lt I/Q TYPE OF CASING: 0 STEEL 0 PVC )�OTHER:TrWofj <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 35 FEE+ TREMIE TYPE TO BE USED: GERS 0 HOSE <br /> 0 AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: Yes 0 No (NOTE: MAX111�UM FREE- L DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: FOrTIANO Ty D£ �� <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH P50 o F T BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR C INNG PROPOSED?�o(if YES,list specifications here <br /> *COMMENTS: �� A p�R O\I2-Y WAR K l�r✓_� Te 0 O <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 Re��ulaootiions, and all applicable Californl ptot Laws.//� / 5 I AG�r <br /> Signedx J. Title/Company r5C FGT V'C� Oiy / <br /> PrintName0 v v' C £//^/ Date 0 3 <br /> DEPARTMENT USE ONLY <br /> u <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �7 T .? <br /> WORK PLAN DATED: �7. /Z'J.'0_04' f� Q <br /> Application Accepted By CIN✓'tJl'_ Date Issued d 0.3 Area dz" <br /> Grout Inspection By Date___ Final Inspection By _ to <br /> Destruction Inspection By Date _ <br /> COMMENTS/CONDITIONS: <br /> ACCQILINTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# I INVOICE <br /> D50 89 Ing y 1 17-4-- 17 1 �m 2. 3 8 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ - 8/29/02 <br />