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WEL&ERMIT APPLICATION PtM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> 46 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 02 OCT 2 I PH 12 304 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 nnDepartmentAssessorIs 23V 6Z <br /> 4'Z4 )j, &J ti/ Cross Street 1'A&W-11/y City-5 V Zip 7�—Parcel# 191" <br /> WELL Location to pptt NNdd p �'yt( <br /> PROPERTY Owner CIZ a-SW1,wf ''`'w" Address 265' .( ,FC Dg4b-0 CitySZ�tr,�-/ ZIP9-�Zd� Phone# (,37 � 7� <br /> �1I -f yy���� '3too 5, �/k.t7`�Ufv citySM�l rlytZip Lic#-t � Phone#&)k�1=�7 3 <br /> C-57 ContractorMl 764911_ 1 V/L(Ld�'Address3 ./n �p„ <br /> Consultant/Sub Cntr <br /> a , E Address ��7 .90W /W Citg 711 Lic# JVJ a 7 Phone# 5�6 7-hod b <br /> Range Section <br /> GIS Coordinates:X <br /> y.,Township <br /> W RK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 OVER-BORE <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> � <br /> VELL# <br /> yt Grout Specifications: <br /> `Other: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?n WELL CASING DIA: Z_ <br /> �,g� t(J TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 EXTRACTION O AIR ROTA R/DRIVEN CASING F GROUT <br /> SEAL <br /> 1 TREMIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> ���0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL <br /> gAIR SPARGE/OZon PUSH POINT GROUT SEAL PUMPED: Yeee`���,.1,,, Il No (NOTE: MAXIM <br /> DEPTH IS 30') <br /> O SOIL BORING O HAND AUGER GROUT SPECIFICATIONS: CQQ..TC.IRLID� 'r ✓t"�' 77 <br /> OTHER APPROX.BORING DEPTH 2S BOLTED TR FFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: 0 <br /> fJ�Q/lGONyD�L/ACTOR CAS NG PROP`JOSED? (if YES,list specifications here): <br /> `COMMENTS: OZaiJC S r -" � Q� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS.�Ill ■ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo9min <br /> County Or ante les d Regulations, and all applicable California <br /> `State <br /> �Laws. <br /> Title/Company J� �� / G•�` <br /> Signed x Date <br /> lO-u"DZ _ <br /> Print Name L DEPARTMENT USE ONLY <br /> J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued AreaZQ <br /> _ <br /> Application Accepted By C at Inspection By I L Date Od-� a� <br /> Grout Inspection By ate <br /> Destruction Inspection By ate <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> -3 S 0s v o a zacz <br /> C-57 WCWAIVER_ C-57 Letter of Authorizat on t n permit—Encroachment doc_ 8/29/02 <br /> = <br />