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was ^ AM <br /> WELL-. E-RMIT APPLICATION FC-,MGUYT <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-34492—' <br /> 1 � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ((�U <br /> Appl,cation 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 /> Joacuin County Devalr) -r Tit[- (han, q-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ,uerr LoEST 6 rr Assessor's <br /> WELL Locatior L.Ow ►J i _ _Cross Street WtL, _Of��.��jCN__ :ity S-�xjc Zip FsSLUL Parcel# <br /> PROPERTY Owner 1 0MWAddress 1(010 LI). il!I1, City SJc(!5d.,+ Zip _ Phone#(Zog)4�(,g•?1057 <br /> C r,A, f�•�w ?.�.�..yyllw - <br /> C-57 Contractor BSc �• Address ��i'L D,,.•ec. G.,,: Li. City_i�_Zip q5-7 VZ Lic # 7ies7sro Phone#(`r6t.-,-e-ti65 <br /> / �Vf N• , <br /> Consultant/Sub Cntr S/cs �• ,N. t.-I Address 1 Y33 it/ 3, A.." City �zvs Lic# Phone#(l oZ�72ss-o�o7 <br /> GIS Coordinates:X(11' i(,' l i�5" Y -�,7• S-6- Sy.��" ,Township ZIJ Range (OE Section 3 C' <br /> WORK TO BE PERFORMED: <br /> N.NEW WELL/BORING(CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) n DESTRUCTION(choose type below) <br /> n SOIL BORING# n OVER-BORE <br /> WELL# KW -iz n PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIO <br /> 'MONITORING 'HOLLOW STEM DIA.OF BOREHOLE 10 'ti MULTIPLE CASINGS? YES NO WELL CASING DIA:Z-Z <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS 0.Il;-Y'- n STEEL g'PVC n OTHE=R: <br /> o VAPOR n MUD ROTARY DEPTH OF GROUT SEAL 3Z TREMIE TYPE TO BE USED: AUGERS n HOSE <br /> n AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: n Yes %No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: IV,--4 !'rte- Z <br /> n OTHER:_0 OTHER APPROX. BORING DEPTH `6';;" ` BOLTED TRAFFIC BOX or n STOVE PIPE <br /> I / / CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br /> 'COMMENTS: r t <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 certify that I have prepared th' pplication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Reg a 'ons, and all applicable California State Laws. <br /> Signed x ^ �/ Title/Company S,LC <br /> Print Name (�,�^" _ (l W. Date �2fl�GZ— <br /> DEPARTMENT <br /> � pUSE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: NO ✓ f /��•�Z '2'y -fl 2— <br /> p <br /> Application Accepted By Date Issued <br /> Area b a <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# PA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> -o �D <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit V, Encroachment doc OV-' 1/25/02 <br /> Ns <br />