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v <br /> WELL PERMIT APPLICATION FOR'ivIi SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT V <br /> ENVIE'JNMENTAL 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 /> ,pplication 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 /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Assessor's <br /> VELL Location -�'�s�Jr� .s• r24--Y puCrross Street City C� Zip_L '1 Parcel# 77� /�50- <br /> 144-S <br /> 'ROPERTY Owner /�f� PAC<r'ri C �A� Address )70 l41c 6,22.-z City 3 p (P,hyyon��e# p p :rte, <br /> ;•57 Contractor <br /> drQ t` k�es T p�Addr ss� 77t!QL.cE�'�'�ycityfA�A Zip 9"Z3'LS .S�7'Phbne# <br /> ;onsultant/Sub Contractor Address City Lic# Phone# <br /> �t' O <br /> 31S Coordinates:X nV A7 10. ,Y W 2­Township_ Range Sectionp��� <br /> �ozw,a !.2;aF i �L gE�'ti +�'"CNa E.0 fe%at ,pfe S4� e 6' <br /> NORK TO BE PERFORMED: DESTRUCTION choose e below) <br /> rNr"NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER`) 0 OVER-BORE <br /> 0 SOIL BORING# r� 0 PRESSURE GROUT <br /> 0 WELL# <br /> Grout Specifications: t71*� CIL" rC I <br /> 'Other: <br /> OMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE__f� TIPLE CASINGS?0 YES 0 NO WELL CASING DIA: <br /> MUL <br /> 0 EXTRACTION IR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR `0 .MUD ROTARY DEPTH OF GROUT SEAL �' Q F`% TREMIE TYPE TO BE USED: 0 AUGERS HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: xYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> � &--n- <br /> 134 <br /> A. cJlld <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: & ,^ <br /> OTHER APPROX.BORING DEPTH 130 F7` BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: D — <br /> ,4 �JIQX�NUM O `rfr`ieEE CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: &U4,, �JL.0< S 6✓!< .c �Lr `�� ?-AL L�A tom` ;�f <br /> (50 A.Jriq",1oV/Ar1060 47' T &' )- .e <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS !N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby. ce I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O finances RWI s an a ' ns, and all applicable CaliforniaStateLaws. �+ <br /> Title/Company GNv/�ONf1fr?.4G JC1 /SO C /fig <br /> Signed x <br /> Print Name � F/eT /7� �' Date ! C/v <br /> DEPARTMENT USE ONLY l <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> �i,G' " Date Issued ��LA / ' � Area <br /> Application Accepted By ? Q i Z d <br /> Grout Inspection By <br /> (% ate DZ Final Inspection By Date <br /> ate <br /> Destruction Inspection By, X <br /> ryl�G i (i` T U� i`1l hLci i <br /> COMMENTS/CONDITIONS: Vr ,-;' ' <br /> ACCOUNTING ONLY: AID# ert <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE ; PERMIT(SERVICE REQUEST# INVOICE <br /> C-57 1 WC -WAIVER' C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />