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WELL-7--ERMIT A rLt-CATION FC,� -A SITE <br /> R CLNED MITIGATION <br /> SAN JOAQUIN COUNTY UNlT N <br /> JAN 2 0 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) ,f I !���v <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 '�` Lei`//�vv(�p��� <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> \pplir2tion 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 /> oaquin County Development Title,Chapter 9-111.115..3 and the Standards of San Joaquin County Environmental <br /> Health Department-Assessor's <br /> VELL Location L72! S w ii l SOYA V/�.C"-tnA Cross Street 6,TA-- t ca City yl_Zp ?;ZyZ- Parcel# <br /> PROPERTY Owner'F Y /-t'f�j h Ct fit- Address S�uY,,f� 1 City ( /L�.�_ZIP SZ SPhone#!<� 64— J <br /> -57 Contractor I/ )( Address 1,9&1'90f I City � Zip_j?jo rTic# d1 hon <br /> ;onsultant/Sub Cntr, /�dM ��,yi Address 8 S '1dt.C1 City '5 Z"Lic#_46.8QZZ2Phone# 'r67��rll <br /> its Coordinates:X ,Y Township Range Section <br /> VORK TO BE PERFORMED: ' <br /> ; EW ELL ®RING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) fl DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 1]OVER-BORE <br /> �NELL# 'Z 1]PRESSURE GROUT <br /> Other Grout Specifications' <br /> ;OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> {`MONITORING fl HOLLOW STEM DIA.OF BOREHOLE 9 rl MULTIPLE CASINGS?I]MULTI-LEVEL?a WELL CASING DIA:2 <br /> EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS C TYPE OF CASING: fl STEELPVC fl OTHER:fr <br /> )VAPOR fl MUD ROTARY DEPTH OF GROUT SEAL'�?S7 TREMIE TYPE TO BE USED: AUGERS 1]HOSE <br /> I AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL.PUMPED: ,fl p No (NOT : MAXIMUM FREE-FALL DEPTH IS 30') <br /> I SOIL BORING 1]HAND AUGER GROUT SPECIFICATIONS: PO 4.o 6o-z /�i O 14a Q¢41'.q--!r <br /> I OTHER: n OTHER APPROX.BORING DEPTH )600'ED TRAFFIC BOX or fl STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_lt(if YES,list specifications here): <br /> COMMENTS: <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 /> Oounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> SignedxZ I I Title/Company <br /> Tint Name �Ot Vl 1 2I vim l l.t�l���.✓� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADORES: 2 5 <br /> WORK PLAN DATED: 11% b a, <br /> Appllgfion Accepted By <br /> Date Issued Area u <br /> Grout Inspection By <br /> Date Final Inspection By ---0ahe <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS[ <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE - <br /> Sp <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit—.Encroachment doc_ 8/29/02 <br />