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�- WELI, L � ..MIT APPLICATION Fr ` f SITE <br /> .SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> �. 304 E. Weber, Third Floor, Stockton, CA., 95202UNIT IV <br /> FILE Ceeir 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 inslall 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 Department. <br /> WELL Location rjVkl !Al_ D` t}'147�� ACross Street V6 +,113;0' hl�,Ci f {G?viTt'C� _ Assessors <br /> ._.._�. ty Zip 5/ 3 3? Parcel# <br /> PROPERTY rPs ++'. LJlU11�1 Del <br /> Owner Mmaj j. iisieq 3P,de',.-�i""Address2T;24 Oi.�.1�.k L(i `Yi City ;; MRr Zip �u- Phone#74 L rs --761 <br /> C-57Contractor�7Ct"cgt'1 �i/I��ti�� Address 950 14cwc, T•l City.N It L Zip?+�,3Lic#'fy'�I(� Phone# 12-5--313-5;900 <br /> Consultant/Sub Cntr&.crvtltr Vt Address W.L,,3 2S ). City.,•,+ti Lic# Phone#'707 135- 4 2.,Sp <br /> GIS Coordinates:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER') [IDESTRUCTION (choose type below) <br /> a SOIL BORING# I]OVER-BORE. DIAMETER <br /> SWELL#_ (]PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t t <br /> 4MONITORING HOLLOW STEM DIA,OF BOREHOLE Q MULTIPLE CASINGS 1]MULTI-LEVEL WELL CASING DIA: <br /> I]EXTRACTION 1]AIR HAMMER/DRIVEN CASING THICKNESSS.C(L"k 40 TYPE OF CASING: a STEEL ", PVC Q OTHER: <br /> 0 VAPOR E]MUD ROTARY DEPTH OF GROUT SEAL-0 [Q.' �TREMIE TYPE TO BE USED: �aAUGERS0I4fHOSE <br /> 11 AIR SPARGEI OZONE 1]PUSH POINT(GP or CPT)GROUT SEAL PUMPED: o Yes 4T-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ©SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS-.F0V+Je,LI.A <br /> (]OTHER: OTHER APPROX.BORING DEPTH : t" S' p BOLTED TRAFFIC BOX or. 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED I10 (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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi a nd ulations,and all applicable California State Laws. <br /> Signed x Title/Company ` <br /> Print Name Fl Date <br /> DEPARTMENT USE ONLY � <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ 1 J 4 0 1 V14. y 0 S e ry, ,ire CA <br /> WORK PLAN DATED: reb truar„ !0�2 0 0 3 �/e3/Dr <br /> Application Accepted By i e— Y Date Issued /1 -10- 03-Area <br /> Grout Inspection By Date 912 Sy d f Final Inspection By Date S x 4, <br /> Destruction Inspection By Dater <br /> COMMENTS/CONDITIONS: z iro U-Ao rvi d I <br /> ACCOUNTING ONLY: AID# FAC# s <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 3 50 1 89.00 84,D0 1801 SR# 003G 007 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />