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�.� WF L PERMIT APPLICATION FORM SITE <br /> %m'' *"W MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> -` 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> r (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 /> II Assessor <br /> WELL Location fol S. will 5cn LJ&,' Cross Street RMSY.P S-6 City `O4cC.�C" Zip Parcel#_ <br /> PROPERTY Owner�'s� pntic -f Address-b pre -fX13� L1C1ity S�rx.k" Zip Phone#JA4-$. Wli <br /> C-57 Contractor W_W DrI1jtu4 C. AddresAAs �b&tL 4lts CityZipo&41 Lic#]ZA5df Phone#cilli-777-4(Ob <br /> Consultant/Sub Contractor 6�oe.nxA �2>4114W j Address IZIu Yvb " EACMk City _Lic# Phone# F3h-11i$?' <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> `KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> / 1� 0 SOIL BORING# 0 OVER-BORE <br /> 2 I-gW ELL# M!�.1 1 S W A. CluSke O PRESSURE GROUT <br /> *Other: Kk) 13 B 1z 5:S 12s4, $"h^h�1 rtio sue 33` Z"cr. 15 Grout Specifications:_ hI 4- [. w Ir- <br /> COMMENTS: p(,W110 Ai, R 19 herj - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS '/ '} lS k8 C 61,4(— (5e�--�S <br /> I r <br /> 'MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE6s/r-127v MULTIPLE CASINGS?0 YES XNO WELL CASING DL4: Z <br /> TO`EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS.$In SIO TYPE OF CASING: 0 STEEL )PVC 0 OTHER: <br /> 0 VAPOR )'MUD ROTARY DEPTH OF GROUT SEAL-;;3.69,In 3' TREMIE TYPE TO BE USED: 0 AUGERS JkHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: lKyes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Nva L rte W <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH S $D IIS' $BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? _(if YES,list specifications here): SSrI�'/a'�S,Irc <br /> 'COMMENTS: kW13Q 6515 $U�'1 'JO-gDrt[-wuf 64& IS7 Pt0"/�7n{ k'�9rOk'(-5�?! c,eN4.wtIL•etu <br /> 1w1� A18 2 xc,e , 35-55`:,fi Z'scra %U 31)`du 5w(5 O-31' 444 ' .NIu1381 AW16A` 9a(!uJ(ax4� tV <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACH ENT PERMITt. <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 Ordances'and Regulations, and all applicable California State Laws. <br /> Signed �G � `^'�^'"Y Title/Company <br /> Print Name Semio Date I112.7167- <br /> DEPARTMENT USE ONLYT �L�.1 15A4 g �t-j A- <br /> r4 ,v.rF tsc w/ tfsA, w w r ro�^J <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 I AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 31501 089 $89 0121 `15 0032320 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br />