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WELARMIT APPLICATION FAM 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) 4684449 - <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 1pplication is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed. This application is made in compliance with San <br /> loaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> `iA£ J,30nr�„un1 CAT4oLte- CEwIrzA-YAssessor's <br /> Q 1VAllo <br /> YELL Location Chu.&tAL Cross Street y�city Fp u-_7-�,l zip �a Parcel# rLs��l>•-3l <br /> Iz .N CAT�i��t� &soP ISO 80 [ 113'7 atySl z�Z / zp`�57_�1 Phone# y[v6- �2oZ <br /> IROPERTYOwner Mr- C'ror:w-�..1 Address <br /> :-57 Contractor i�tli(i!ELi_ l�.rc�liru/ Address S3bu S. wk/`7 AU/ Citny•- if np9 - .L ucrr�hone#`�/6 G3/-35 3 <br /> :onsuitantI Sub Contradorl\.Lj• E Address `hJ-7 S lAf- ) TAD City Uc#L%!�2'z7 Phone# <br /> 'IS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PE ED: <br /> kNEW WELL/ RI (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# n OVER-BORE <br /> Q WELL# 0 PRESSURE GROUT <br /> Other Grout Specifications: <br /> ;OMMENTS: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING )1)(}1 <br /> 0LLOW STEM DIA.OF BOREHOLE u,��� " MULTIPLE CASINGS?0 YES n NO WELL CASING DIA: <br /> 1 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS,TYPE OF CASING: o STEEL a PVC 0 OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL"TD Ccy_ TREMIE TYPE TO BE USED: Il AUGERS HOSE <br /> I AIR SPARGE a PUSH POINT GROUT SEAL PUMPED: )(Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING o HAND AUGER GROUT SPECIFICATIONS: �J ,-C,4/AID /-VA, <br /> IS <br /> OTHER: p OTHER APPROX.BORING DEPTH D 11 BOLTE TRAFFIC BOX or 0 STOVE PIPE <br /> Q� �p� CONDUCTOR CASING PROPOSED?�_(if YES,list specifications here): <br /> COMMENTS:2 L- G.64A(4s TU •��>U+ ro — 6-0"&0 l/4T6ic <A-P�'fLlt" <br /> 1�t Lf 1 ICY,( <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty(�,rr�In)ance Rule and Regulations, and all applicable California State L/awws./ <br /> ignedx 1 -f �� TitlelCompanyc�r( -0{AJk�.LEf> CrfczAl�tQ. n,.f.Af7AL- <br /> �iR.L�- -�TSbAI- Date <br /> tint Name <br /> DEPARTMENT USE ONLY <br /> ;ITE MAP IN UNIT IV FILE,ADDRESS: <br /> VORK PLAN DATED: <br /> /p 2� <br /> pplicaticn Accepted By V V Date Issued <br /> 0-74 <br /> 20t)Z Area <br /> rout Inspection By Da Final Inspe on By Date <br /> estruction Inspection By Date <br /> OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# � BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> u r _71_4V SR# 3U ) <br /> :-57_ WC=WAIVER_ C-57 Letter of Authoi'i ti to sign permit_Encroachment doc_ 1/25/02 <br />