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WELL PERMIT APPLICATION FOMVI 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 /> 1plication 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 /> )aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �1p,� Assessor's <br /> TELL Location ,3033.0 S• rU--Y BAyCrrossStreet City 7/u'►C� Zip 9.r37� Parcel# ?%6 1350-9 <br /> ER1.4cS p.ZS <br /> ROPERTY Owner ;P-74f-74f /p AC//r�C H T Address p0$OK .1.2 SZ City e4 S ,Vr" Zip Y �,g Phon�e# <br /> -57 Contractor l�� 4 �✓E S T D�Addr ss�-5 77 7 ✓4,941Y 3.4✓D�y fovr vA✓azip 9�3�s si 7� ne# 909 356-0200 <br /> onsultant/Sub Contractor Addres CityLic# Phone# <br /> �/ Off/ <br /> ;IS Coordinates:X y/ .s.]7 Teo•ao ",Y w A&%M j6 ,Township_ Range vim-` Section <br /> ZfieivR L SE�criow !�'"�'iIo E.0 0Z4 .4 S4.v <br /> WORK TO BE PERFORMED: <br /> NEW WELL/'BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> Other: Grout Specifications: Cil U+ .0,/. SO hd <br /> ;OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?BYES []NO WELL CASING DIA:_-.1111 <br /> ]EXTRACTION )(NAIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> ]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ^' D F� TREMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED-XYes 0 No (NOTE: M"MUM FREE-FALL DEPTH IS 301 <br /> (SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS:, 1 3C�• SGI�d <br /> ]OTHER:_G OTHER APPROX.BORING DEPTH 130 dgr BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ,4 -%,* c/NUM O x, rfYiefE CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: Nav/ToRelayis zJrA4 $ L✓/< .0 3E /AtlS )'A- 2,e EA /A /�f7•�QCELfy <br /> eo Nr-,0q",oWg7/0a 4s- ENcou.✓rf efb Aq" 7,41Z W.4Y—fZ Ti4,8af <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 ce I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County nances I s an a ' ns, and all applicable California Laws. <br /> Signed x Title/Company GN�/A�D�/�1E�YAGyq�/,SSD C ? <br /> Print Name I'.7" EWyk --,-,qo) Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �n / <br /> Applicatidh Accepte4By, <br /> C�w Date Issued A V �` Area <br /> Grout Inspection By ate Z Final Inspection By Date z D <br /> Destruction Inspectiate <br /> ry <br /> COMMENTS ICON DITIONS: �" ✓ � �`t <br /> c (Orth ULr <br /> ACCOUNTING ONLY: AID# 5 cent <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O0 <br /> C-57 WC -WAIVER C-57 Letter of Authorizati n o Sidn permit 1/25/02 <br /> Encroachment doc <br />