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WELL _ Ek"MIT APPLICATION R ZM SITE <br /> -� MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> JAN 2 0 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ;j ji+i.vNMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> b 4 fGq <br /> NON-REFUNDABLE PERMIT IXPIRES 1 YEAR FROM DATE ISSUED application is made in compliance with San <br /> on is hereby made to San Joaquin County for a pennif to construct and/or install the walk described. This app� Assessors <br /> County Development Title,Chapter 9-1115..3/and the Standards of San Joaquin County `dm HealthIDepartment1 Parcel# <br /> ocation a( UZ D'fW Cross Street 6 i np_��ty y y�1�,�0 /,,,,,�l� �tQ <br /> ) C / ( / �l r t 7 Cil} ZPl--Y-Phone#�"/I/�1 J <br /> �r-F1J L S/ZX-KTC� Address..- <br /> RTY Owner /GL(vc-r^`o ���j� i,�(�j l hone# <br /> 2 �lu,�i C CIA: City�YY�OJ/4-ZP`= Q� <br /> —Q'"'� �9 6� <br /> ntraGor .ddress 6 7 <br /> Address City­ <br /> 37 "J Td Li ��--Phone# _— <br /> ant/Sub Cntr Section <br /> Townships—mange <br /> xdinates: Y - <br /> T RFORMED: p DESTRUCTION(choose type below) <br /> WELL/ ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 OVER-BORE <br /> SOIL BORING# [j PRESSURE GROUT <br /> ELL# Grout Specifications: - <br /> TENTS <br /> ;ECONSTRUCTION SPECIFICATIONS WEINSTALLATION TYPE <br /> ITORINn HOLLOW STEM DIA.OF BOREHOLE 6 / MULTIPLE CASINGS?I]MULTI-LEVEL? <br /> WELL CASING DIA <br /> WELL Z// <br /> 2ACTION Q AIR HAMMER/DRIVEN CASING THICKNESS ftI� PVC n OTHER: <br /> PE OF CASING: 11 STEEL <br /> DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: AUGERS fl HOSE <br /> JR 0 MUD ROTARY No N f0'TE: MAXIMU FREE -DEPTH i'SL �U')l �I <br /> SPARGE/OZOne PUSH POINT GROUT SEAL PUMPED: 8 p y"7 ` 6 iIg tLv <br /> BORING p HAND AUGER GROUT SPECIFIC; [� <br /> OL7ED TRAFFIC BOX or []STOVE PIPE <br /> n OTHER APPROX BORING DEPTH_ i <br /> ER: � if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED.4R.(i . <br /> VENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> at the work will be done in accordance <br /> eby certify that 1 have prepared this application and thpwit�h,S¢a� <br /> � n Joaquin <br /> nty ordinances Rules and Regulations, and all applicable California Ste Laws. <br /> � l S� � ^ <br /> n rne/cornpany �t � <br /> I IJ. C. ' lti Date <br /> Name '^ ° DEPARTMENT USE ONLY ! <br /> i <br /> 9 MAP IN UNIT IV FILE, DR S: 26 Z s ' <br /> RK PLAN DATED: % <br /> Date Issued7 / I Afea <br /> .cation Accepted By Date Final Inspection Ca <br /> Date <br /> '.t Inspection By Date <br /> ruction Inspection By <br /> AMENTS I CONDITIONS: <br /> 1COUNTING ONLY: AIDC <br /> RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> .CODES FEEINFO AMOUNTREMRTED CHECK# �� Z-0�.00 �$ I ZbD <br /> p 8/29/02 <br /> orization to sign perm <br /> 57_ WC=WAIVER_ C-57 Letter of Aut <br /> permit—Encs�h <br />