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r� <br /> WELLYEFtMIT APPLICATION Ft�— '.M SITE <br /> j MITIGATION <br /> PAYMENT -SAN JOAQUIN COUNTY <br /> RECEIVED UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD). <br /> .JUN 2 6 2003 304 E. Weber, T4ird Floor, Stockton, CA., 95202 <br /> J1. <br /> (209) 468-3449 SAN JUMUUrN CUJ�T`! <br /> i. ppg{1 I{Ep_ih aER4��LS NON-REFUNDABLE FERMR EXPIRES'I YEAR FROM DATE ISSUED <br /> I Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application's made in compliance with San <br /> Joaquin County Development Title,Chapter&1 t i5.3 and the Standards of San Joaquin County <br /> mental Health 7,,JlthDepartment Assessor's <br /> ' <br /> 7(� Parcel <br /> I WELL Location 2�f.�d l OS�� �D Cross Str`ye�/est GQTA/ L//`�,y1}�City <br /> Zp J 6 y� Phon '� -4 i <br /> PROPERTY Owner � - �� Sa • Address �'�IOD LJS�� 1-- Ciiy <br /> zwl 7 <br /> C-57 Contractor_ cltyLER .�TP'��7GO,cf,�7 Phon [JG ]f�� J <br /> Consultant/Sub CntrOify�Lic3? -Phon <br /> Y ,Township _ Range Section <br /> GIS Coordinates:X _ <br /> PEI <br /> RK TO BE PERFORMED: !j <br /> EIW WELL/BORING(CPT,G ,OPROBE,HYOROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION(choose type below) <br /> SOIL BORING# I a OVER-BORE <br /> `� WELL# Mut"(--n 6',AL i- /Lnd-7 QPRESSURE GROUT <br /> 'Other: WWI Spedfications: <br /> COMMENTS II - <br /> 'I <br /> i <br /> E OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING HOLLOW STEM DIA.OF B I CREHOLE­tL MULTIPLE CASINGS?1]MULTI-LEVEL?0 WELL CASING DIA_ <br /> o EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESSSENT TYPE OF CASING: 1]STEEL ..)rPVC o OTHER: <br /> 1]VAPOR 0 MUD ROTARY DEPTH OIF GROUT SEAL i/R2co _ _TREMIE TYPE TO BE USED; AUGERS HOSE <br /> a AIR SPARGE/Ozone 1]PUSH POINT GROUT SEAL PUMPED: YPg�ls Q No (NOTO�M (FREE-FALL DEPTH IS 30') <br /> U SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS. /GRTL.Afic� r <br /> OTHER: t)OTHER APPROXI BORING DEPTH /fNckS OLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASINP PROPOSED?_ �._(if YES,list specifications here): <br /> `COMMENTS: G' J <br /> it <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 app <br /> licafion and that the work will be done in accordance with San Joaquin <br /> County rdl nc at Re lations, and all applicable California State Laws. A�U,Ak(cE <br /> j Signed x Title/Company 7 14rEa�v <br /> Print Name <br /> DateD6 — — � <br /> DEPARTMENT USE ONLY D <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C),k 31 2o02 <br /> r <br /> Application Accepted By :i Date Issued Z6 d Are <br /> Grout Inspection By L�-Date �i Final Inspection By Date <br /> Destruction Inspection By Date <br /> fI <br /> COMMENTS/CONDn10NS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI# RECD BY DATE , PERMIT/ RVI _ E EST# INVOICE <br /> C-57_- WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 8/29/02 <br /> ' � a <br />