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WELAERMIT APPLICATION F&M SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> JUN 19 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 O IG"DI L <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health V�/ Department <br /> ) 1' ' MARKPT ST Assessors <br /> WELLLocation / D/ S. W;400 •I ,j oss Street tvd5en WAY/C� STDC.K[Dr1 zip " <br /> ity 9Wo. parcel# <br /> PROPERTYOwner F^rD/Lj I Address � 77a Gd1 S /1 city-s -r ,l(TOn�Z,p 95a/5Phone# Z`�f-4/b34- 3e <br /> C-57 Contractor CHS D i%;1j,' Address 3632 OM£t. umhncity c Azipgs7y2-Udt:7l S/oPhone# /b 65& 1169 <br /> Consultant/SubCntr Address-537 1944W RaClty6-TP—OrZlic# 6SoZ27 Phone# e5 x/67 / 00b <br /> GIS Coordinates:X ,Y Township _ Range Section <br /> WORK TO BE PERFORMED: <br /> rEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION(choose type below) <br /> •` 0 SOIL BORING# n 0 OVER-BORE <br /> )IrWELL#_ F-W- w^ I I 0 P SSURE GROUT <br /> 'Other: Grout Specifications: of 1/A�,D l•y�E <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )[ f ONITORING OLLOW STEM DIA.OF BOREHOLE 1 S MULTIPLE CASINGS?11 MULTI-LEVEL?)(WELL CASING DIA: <br /> /1rysw/£ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS !JP TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2SF I TREMIE TYPE TO BE USED: AAUGERS 0 HOSE <br /> p AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: " 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 1]SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: OAT A J,) CF"✓1 <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH _S S FT ;WOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> Il e CONDUCTOR CASING PROPOSED? No (if YES,list,specifications here): <br /> `COMMENTS: //P�IIF�VgD - 7n-}rr;+h RfMFDrAT�or� Irupr•t; Y�4N ...I�T£D 'LIM y <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 this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed z / 7 Title/Company n, EC i L79£ <br /> Print Name /r M j . ca/�JR, � ) Date (t7 b ' Z003 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l 0 ) S• (.t I Sovt Wa K`bc k fit/ 64 <br /> WORK PLAN DATED:�/� Z ( ,M1a� Z as 3 <br /> Application Accepted By - / u"t C��/ro�.c,/>D Date Issued 0612 Y/U 3 Area IV S' <br /> Grout Inspection By Date Final Inspection By 7 Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Wir< --11Z3 a,61a3 - .arc y 7 // o <br /> ACCOUNTING ONLY: AID# <br /> PE CODES i FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 Mw �9 f 8779CNTk /9 03 SR 063y372 <br /> C-57--ZWC �­­tWAIVER_ C-57 Letter of Authorization to si n permit_ Encroachment doc/L/4 8/29/02 <br />