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NEC`1 D IIIIELL PERMIT APPLICATION ;'FORM SITE <br /> NEC_ la <br /> k - MITIGATION <br /> APR 2 0 2004 SAN JOAQUIN COUNTY '` UNIT IV <br /> „ EiT ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 'I '1Sl:R i1 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PEI-Ii,�llT,�� j +,FS (209) 468-3449 I <br /> NOW REFUNDABLE PERMIT EXPIRES'-YEARFROM HATE ISSUED <br /> Application is hereby made to San Joaquin County for a pemlit to construct andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 i Assesso�s <br /> q �. }��r �Gl CiI1 S4,.,!k �c:n Zip `��� � � Parcelm <br /> WELL Location ` r Crass Street ty <br /> lk.. �,,. Lea <br /> }, }� �',n* n F 1l Zi l Phone <br /> U,;�:, Frtc �;� �fl �rc Address `i� �c S4 1p City ase, p951`1 gl <br /> I PROPERTY Owner 1 L <br /> ZIEa car• S�,Ce�City5^^ L�. �rizip�'jS�7tic#�c' i lPhonert E <br /> C-57 Contractor <br /> V f o M1��" Address J _ <br /> m-T �,A,I h� �� ,;Ccity'f�^'al'u� [rP'Lic# Phone,: 9� <br /> Consultant l Sub Contractor �`� Address y <br /> I} <br /> Section <br /> GIS Coordinates:X2 i ,Y N 3.1�' Towrship_ ; _.Range — <br /> .1 <br /> WORK TO BE PERFORMED: ��` DESTRUCTION(choose type below) <br /> 0 NEW WELL/BORING(CPT•GEOPROBE,HYDROPUNGH,HAND-AUGER,OTHER-) I. []OVER-BORE <br /> SOIL BORING# I XPRESSURE GROUT <br /> p WELLiv C <br /> # Grout Specifications:� e" x <br /> *Other: Il E- <br /> COMMENTS: <br /> TYPES L INSTALLATION TYPE CONSTRUCTION SPECkFICATiONS <br /> HOLLOW STEM DIA.OF BOREHOLE�r.MULTIPLE CASINGS?[]YES []NO WELL CASING DIA: <br /> XMONITORING a 11 TYPEbF CASING: Q STEEL 17 PVC U OTHER: <br /> 0 EXTRACTION 0 AIR HACASING THICKNESS rr <br /> 11 <br /> DEPTH OF GROUT SEAL i Ti EMIE TYPE TO BE USED: []AUGERS a HOSE. <br /> VAPOR 0 MUD ROTARY <br /> li AER SPARGE PUSH POINT GROUT SEAL PUMPED: o Yes No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 3>7 <br /> GROUT SPECIFICATIONS. I} P <br /> [] <br /> SOIL BORING HAND AUGER ` BOLTED TRAFFIC BOX or I1 STOVE PIPE <br /> OTHER APPROX.BORING DEPTH <br /> ©OTHER:_ g v if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED. { <br /> Gf, <br /> 4 <br /> *COMMENTS: G <br /> i, �4� r.,.,�r �e� ��� l; F+ ' <br /> I i,i... Mn <br /> u: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS;ON ACENC <br /> CALL R QUIRED 1NSPEC SoNs. <br /> CALL THE UNIT IV INSPECTOR 4S WORKING HOURS IN AD� <br /> re aced this application and that the work wlll be done in accordance with San Joaquin <br /> I hereby certify that I have prep <br /> nd Regulations, and all applicable California State taws: <br /> County Ordinances, Rules r <br /> Title/Company <br /> Signed x 1 , i L4 i,1�� l <br /> Date <br /> i. Print Name "^ ` L`` DEPARTMENT USE ONLY <br /> .j <br /> I; <br /> SITE MAP IN UNIT IV FILE,AD RESS: ii F <br /> WORK PLAN DATED: I <br /> I 0 Area . <br /> Date issued <br /> Application Accepted By q 2 d Final Inspection By <br /> Date_ <br /> Date <br /> Grout inspection By Date I3 <br /> Destruction Inspection By [i N <br /> COMMENTS 1 CONDITIONS: - P <br /> it I <br /> ACCOUNTING ONLY: <br /> AID# cerft l <br /> AMOUNT REMrrTED CHECK# REC'D BY,J DAT PERMIT l SERVICE REQUEST# INVOICE <br /> PE CODES F E INFO SR# S7 <br /> S <br /> 610 <br /> ?-D I/2 <br /> C-57_ WC�-WA <br /> C-57 Letter of Authorization to sign permit Encroachment doc" <br /> IVER <br />- t <br />