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t i k Ibl L <br /> WELL ��RMIT' APPLICATIOFQ JIN,! SITE <br /> RECE NED SAN JOAQUIN COUNTYMITIGATION <br /> UNIT IV - <br /> SEP 10 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Sto6kton, CA. , 95202 O� <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> SERVICES <br /> f PERMIT NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> %pplication is hereby made to San Joaquin County for a permit to construct andlor 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- <br /> l� 1 ��jj Assessors <br /> YELL Location 1250 N. W.I&on wd0.v _ _ Cross Street a<rdi;n City S{UC.1C aN Zip 9,Td 0 Parcel# <br /> oC /�1 Address �[ZS /Il• �.0 �i57� ,.� II <br />{ �RQPERTY Owner�f��/ (� - _ _ _ 7- _ --- ..,... . _w- _ _.—Zp Phone#� <br /> r y ..S <br /> -57 Contractc &uLeI+u � i— h Address�Sa [ja�c�� 1� �CitY Zip' Lire,`O :lhone#_1ZS 3 a 5PO4 .� . <br /> � a <br /> :ansultant I Sub CntrkAddress 837 5bac.1 Q Cytsn7' I00(a <br /> I <br /> FIs Coordinates:X 37. �6 `�Z ,175 053 Township 'Range !' Section <br /> NORK TO BE PERFORMED: <br /> 'l <br /> IN EW WELL 1 BORING(CPT,GEOPROBE,HYDR PUNC: .HAND-AUGER,O ER') n DESTRUCTION(choose type below) <br /> .SOIL BORING#_C$T= r G P T" Q OVER-BORE <br /> II WELL# Q PRESSURE GROUT <br /> .Other: Grout Specifications:77 1 <br /> :,OMMENTS Ort eGS+ Lan e W It <br /> rYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DEA.OF BOREHOLE�tL_MULTIPLE CASINGS.? MULTI LEVEL? WELL CASING DIA: <br /> ]EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS__hl ATYPE OF CASING: U STEEL [jPVC O OTHER: <br /> j VAPOR ©MUD ROTARY DEPTH OF GROUT SEAL T U =TREMIE TYPE TO BE USED: n AUGERS HOSE <br /> AIR SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED: $Yes p No (MOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> :SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: T o Svc �c1p r t~ roo� <br /> OTHER: 0 OTHER APPROX.BORING DEPTH I?.O / i Q BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? N A_ (if YES,list specifications here): <br /> 'COMMENTS: Ol bQCon �O�G { a ar.n ec QCa �i4rti 1 G T C_L L <br /> Gnc afovj <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� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ) <br /> Rules a Regulations, and all applicable CaliforniaState Laws. <br /> County Or s, 9 ,� <br /> i� <br /> Signed AfTitielCampany BA+ Cr Aluonf..h Geonrr <br /> Print Na <br /> it Date ��O <br /> f DEPARTMENT USE ONLY, <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: S <br />! t I A( O b <br /> I d Area <br /> Application Accepted By Date Issued <br /> i <br /> Grout Inspection By Date Final Inspection 13y ate I <br /> Destruction Inspection By Datef F <br /> COMMENTS 1 CONDMONS: <br /> Ih ACCOUNTING ONLY: AID# # j� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> .p <br /> Fel- ADD l -�� 55 .3 <br /> C-57 WC 11UAIVER C-57 Letter of Authorization to sign permit i En-crroachment # <br /> to i. 9 <br /> r Rig <br /> �k I <br />