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WELL 1-i�RMIT APPLICATION FOmVI SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1ppllcatlon 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 /> ioaquin County Development Title,Chapter 9-1115.3 and the Standards of Si Joaquin County Environmental Health Department. <br /> YELL Locational�JS/•r U/1 L- �/,u.I¢� cross so-eet,�luo.Y /� city iL7 i/iP Pam Assessor's <br /> 'ROPERTYOwner—Al�?f;lifso C��4h9r�_A�d7dress 2/O/K1y� ' a _Cny,S9 ey(���'��Zp 0,5 Phone# <br /> :-57 Contactorlf-[7G Address 2ZS gIM2e Citut YZCX ZIP&--'.2J FIZZ Phonel(.l'094/e7/006 <br /> :onsultant/Sub Cwtmcbr .�rC Addrew-S2 S{1LvuJ ,l�l1 city6aKk ryJ JLidWozz7 Phone(f2U94671001,.� <br /> ;IS Coordinates:X ,Y Township Range Section' <br /> YORK TO SE PERFORMED: <br /> I NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 11 DESTRUCTION(choose type below) <br /> 1]SOIL BORING# 7 ErA(o L r u OVER-BORE <br /> Other: <br /> SWELL# Aft/-Mrti- z aPRESSURE GROAT <br /> :OMMENTS: Grout Specifications: <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> k MONITORING IkHCLLOW STEM DIA.OF BOREHOLE .I Zf MULTIPLE CASINGS?a YES ONO WELL CASING DLA-.,2 <br /> I EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS !e ` ,'IO TYPE OF CASING: a STEEL ❑PVC p OTHER: <br /> I VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL 4/5 / TREMIE TYPE TO BE USED: IKAUGERS u HOSE <br /> I AIR SPARGE KPUSH POINT 'GROUT SEAL PUMPED: Ig Yes 1]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `KSOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS: �. 7'Zfb✓D [_I w T— <br /> I OTHER: tl OTHER APPROX.BORING DEPTH !�S r 1]BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A'U (d 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 /> :ouin Ordil noes ule Regul ions, and all applicable California St/a/te/Laws. <br /> igned x Titie/Company <br /> nnt Name 0 Date 7/2 Z/D-Z <br /> DEPARTMENTI ,USE O;ITE MAP IN UNIT IV NLY �f �- ( <br /> ORM PLAN DATED:FILE,A p1E S Y 5 L ^� 1 (� �a� . 3+6 �"C� <br /> pplication Accepted By IL Date Issued r1 �- 3 D ik Area <br /> rout Inspection By Date b / 07- Final Inspection By Date <br /> estruction Inspection By Date <br /> OMMENTS/CONDITIONS: n i L1) <br /> ACCOUNTING ONLY: AID# <br /> cer4 <br /> PE CODES AMOUNT REMITTED CHECK# REC'D BY DATE ERMR I SERVICE R OUE # ICE <br /> 3Sol 1112.3 s -30S - <br /> :-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign" <br /> rmit Entroaeh6ent doc_ 1/25/02 <br />