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WEI. ' "ERMIT APPLICATION P`)-",M SITE <br /> I SAN JOAQUIN COUNTY' I MITIGATION <br /> ENVIROENTAL HEALTH DEPARTMENT ( D) UNIT IV <br /> It �," ropy 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (� L COPY (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 vrork described. This application is made in compliance with San <br /> i Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> U �i Assessors --77 <br /> WELLLocatiodw to. t0-'1(Mi4GnUe.. - . Cross Street& (to;D71 M.City "af4ec-e Zip Parcel#„2/q-0)_0-3,Z <br /> _ P <br /> - tT �5 7 <br /> iI Ownef((A0.MA5 i�(tfinTT Address.2FOto ViC4C(7k&#'. acityp/Pt7SCb1 .0K Zip - Phone 92s) ���-'u 7 / <br /> C-57 Contractor GrPn.-r4 (Jyf ll�pTAddrreessrs1• iSb Agar 'N. C1'f�Yf.tZ Zip`?�SS,jLic#��i65.Phone 4z5)=3t3-.5!!25D <br /> Consultant/Sub Crit hurt"+ -rcL G'�t�l� '” Address QE'.��(TX '2 City Jr i'LCA''� Lie# Pnorie#7CJ7 - may=27 <br /> GIS Coordinates:X ,Y .Township - Range Section <br /> WORK TO BE PERFORMED: - <br /> 'ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) B DESTRUCTION (choose type below) <br /> B SOIL BORING# B OVER-BORE. DIAMETER <br /> >IJWELL# W- 4 aA - UPRESSURE GROUT <br /> B*Other - - GROUT SPECIFICATIONS <br /> COMMENTS: <br /> l <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - <br /> `gMONITORING �B.HOLLOW STEM DIA.OF BOREHOLE ,t <br /> �{ B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA Z <br /> B EXTRACTION B AIR HAMMER/DRNEN CASING THICKNESSSCIVA 40 TYPE OF CASING: B STEEL %jWC BOTHER: <br /> B VAPOR B MUD ROTARY .DEPTH OF GROUT SEAL =L(2 TREMIE TYPE TO BE USED: AUAUGERS"� '$'HOSE <br /> { B AIR SPARGE/OZONE B PUSH POINT(GP orCPT)GROUT SEAL PUMPED: a Yes No T(NOTE: MAXIMUM FREE-FALL.DEPTH'IS 30') . <br /> :B SOIL BORING B HAND AUGER GROUT SPECIFICATIONS Pe Ate-t� T&- <br /> a OTHER: fl OTHER APPROX.BORING DEPTH ' .3S r B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED- l.i U (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> f 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> j County Ordinances, Rules and <br /> aa <br /> aand Regulations, and all applicable California State Laws. <br /> Q1 <br /> - <br /> Signedx 0 �„C. .4 \ a. n Ye^ A.� Titie/Companyyic-i<7i 0IES ),ELI <br /> Print <br /> r � t-�- <br /> Print Name Cy{Q.i S C N 2-lS 1�.t`SEt� - - - - Date 1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: JJ G D LII. YDSemd7tfe, <br /> WORK PLAN DATED: FBMYrISrU /O inn 3 <br /> l Application Accepted B _r�Y1C�� 7 .. Date Issued - Area9 <br /> Grout Inspection By Dale S/ /64 Final Inspection B Date - <br /> Destruction Inspection By - Date - -COMMENTS/CONDITIONS: 1: f'h 1 r J ' <br /> ACCOUNTING ONLY: AID# - ,FAC# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# - REC-D BY DATE PERMfr/SERVICE REQUEST# INVOICE <br /> 350 ) B9, 00 P9: 60 / 800 ISR# 6631770-2 <br /> C-57 WC_-WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />