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W�_L PERMIT APPLICATIO" FORM 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 /> 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.chanter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> AssessWELL Location.('02 S• W,I son we„y Cross Street 1�tM(VRA- S� City��,�t Zip Parrcel# nr� <br /> o _ _ <br /> PROPERTY Omer Euk --rf Address4bPim 3003s- City S� Zip Phone#4116 -$;4U <br /> C-57 Contractor AW 1-,1 1 t4 = _Address Bot. 4lrs City _Zip�641 Lic#2Z&jg hone#rl(6'777-4/0(L <br /> Consultant/Sub Contractor 6vbuwJ Zecr)/hl_9j Address1Zlu�r",+ City5Cjjai Lic# Phone# <br /> GIS Coordinates:X ,Y Township Range Section ' <br /> WORK TO BE PERFORMED: <br /> `YVEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> a SOIL BORING# a OVER-BORE <br /> DELL# M 1 A.R. CI -4e a PRESSURE GROUT <br /> K)U 13B 'h5� <br /> •Other: '61r , 8"6m-1141 Cmx sera 3-1` Zf os•) Grout Specifications: k)M4, reMAI#Aj- <br /> COMMENTS: b(1rJlb at <br /> R f 8Ah he <br /> to p r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS AW 15 Ab ` C e1.4f— <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE6s/a-12% 'MULTIPLE CASINGS?a YES $NO WELL CASING DIA: 2b <br /> //a,,EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 5C4 4D TYPE OF CASING: a STEEL )'PVC 0 OTHER: <br /> a VAPOR XMUD ROTARY DEPTH OF GROUT SEAL-33'66,Ie2- TREMIE TYPE TO BE USED: GAUGERS HOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 1KYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS: Nib� Pe 1u ju r <br /> a OTHER: 0 OTHER APPROX. BORING DEPTH �Sp;11 S` J BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? _.,,J(if YES,list specifications here):qg-!4 f '/q`r 51re.) <br /> *COMMENTS: Awa 13 � 65tlsy , ScfwA70-V/ C-wi d-$6'{s9 'II'Y`v w�9rOk{-Sl+ae Q e4M4-v.tietcl; <br /> W ll, A!B (A 2"screa 35-55' Z'rtre X-341`9)SE-6 0-30"k' ,'10130 1 tJ)(,A: 6 14 ja`h,&,Jku <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACH ENT PERMIT . <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 Ord anc es and Regulations, and all applicable California State Laws. <br /> Signed z Title/Company 1 1p3ys r lhir �q���ti <br /> Print Name se6 K) c1 ry± Date I I I Z']16'— <br /> DEPARTMENT USE ONLY jW 15A4 fit-, <br /> -Ke. ,wr G✓c. tSC wJ (fs�,n,.c-,w.e rof�y. <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: I AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOIC'c <br /> 355 f T e5 1 012145 0032320 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc 1/25/02 <br />