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WELAERMIT APPLICATION F r M SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <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,Chapter 9-1115.3 ar)Q the Standards of San�E Joaquin ounty Environmental Health Department. <br /> Assessor's T1� 9 33b <br /> •5 Parcel# 219 -3 <br /> WELL Location %,yp2��ll�.J W .I����11 kJrlf7�., Cross Strptreeepet p • .l5/•1F City f�N Zip <br /> PROPERTY Owner 7IT rG IE I dF Q Address Y OO O �htrr TVt City /jAN ft(R zip 4•g33 phone2";' I3N11 <br /> //'� (� ANw4P )515br <br /> C-57Contractor(A5CA•! PA;jjln� Address36✓Z�MF-CC ircle CityC ADA.,I}_Zip Lic#7/j5/10Phon <br /> 01 bg°z27 <br /> Consultant/Sub Contractor A • r F Address f 3•] SHA.,, /�C•CityS'roC KfunLic#-Phonek7 Y 7�0 Q b <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION choose type below) <br /> Yd NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) a <br /> /'� 0 SOIL BORING# 0 OVER-BORE <br /> WELL# MW <br /> 0 PRESSURE GROUT <br /> *Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r/ <br /> MONITORING HE <br /> OLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?BYES XNO WELL CASING DIA: <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS Sch y t TYPE OF CASING: n STEEL VC OTHER: TEF&rJ <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL ZS F'F• TREMIE TYPE TO BE U5 JKAUGERS 0 HOSE <br /> H AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING n HAND AUGER GROUT SPECIFICATIONS: A4 Ty Pee. <br /> n OTHER: p OTHER APPROX.BORING DEPTH 17,S F7. BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 547 rr(o�.J+- CONDUCTOR CASING PROPOSED? A/Q (if YE S,list specifications here): <br /> *COMMENTS:- 5.%E fi <br /> E ." L f nR r. P k^ Co+EO O'1 APS G Z 0 O Z. <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/J5��ate Laws. <br /> Signed x <br /> ` Title/Company / kg Q� z r- I �� <br /> rAp- <br /> Print Name Date aT/fi \ E Date 0 2- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / // <br /> Application Accepted By 1. � Date Issued 91 2-0 / 240Area <br /> Grout Inspection By Date Z Final Inspection By Date <br /> Destruction Inspection y Date <br /> COMMENTS I CONDITIONS: Y <br /> 7 <br /> ACCOUNTING ONLY: AID# cnre <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' Y DATE PERMIT I SERVICE REQUEST# INVOIC <br /> ' 0 10k SQ.oa (o W SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Autholiz o sign permit_ Encroachment doc_ 1/25/02 <br />