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WELL .11RMIT APPLICATION FdlIPM SITE <br />NME.NTAI. HEW it SAN JOAQUIN COUNTY <br />MITIGATION <br />SERV1iNVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />02 SEP 16 pm OH E. Weber, Third Floor, Stockton, CA., 95202 <br /> <br />(209) 468-3449 - <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />koplication 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 />roaquW <br />I <br />Coveloprnent Tjtle, Cbapt 9-1115.3 and the Standards of Sao Joaquin County Environmental Health Department. <br />,)De1461/4 0.) Assessor s <br />VELL Location lotswieb Cross Street City -5/19Gie754-k7 Zip1623>2-- Parcel# <br />r4; e <br />'ROPERTY Owner $,9,1 jbayhtm C6 Address20 C .5-1196/1-1--tivl Ziptd I Phone# <br />/ / _Af-7, ,k4me.k7-171,:,,e74, <br />--..-- 9v.,s-----2. ....P',195- '..2-5 3/2 5S0 0 :-57 Contractor6tIT iii "-- _cf Address 0 1-1 Mei- _10.e.e-- City p ..,Lltar _ _Phone#• <br />.8--7 -- \ --- 4 t-‘) 44- City SY9 c- gipc# Phone# 4/&7 /063 ;onsultant / Sub Contractor eti-Kr7 Address <br />;IS Coordinates: X , Y , Township Range Section <br />YORK TO BE PERFORMED: <br />XJEW WELL / BORING GEOPROBE, HYDROPUKH, HAN9-AUR, OTHER") <br />Al/SOIL BORING # fie <br />ti-WELL # <br />Other: Grout Specifications: <br />;OMMENTS: <br />a DESTRUCTION (choose type below) <br />[3 OVER-BORE <br />a PRESSURE GROUT <br /> <br />YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1 MONITORING [3 HOLLOW STEM DIA. OF BOREHOLE :2-, 4e-6i MULTIPLE CASINGS? [3 YES [3 NO WELL CASING AM- <br />I EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS /v74 TYPE OF CASING: a STEEL [3 PVC a OTHER: <br />I VAPOR [3 MUD ROTARY DEPTH OF GROUT SEAL 66(-1,1?___ TREMIE TYPE TO BE USED: [3 AUGERS ,,Er4OSE <br />IAIR SPARGE [3 PUSH POINT GROUT SEAL PUMPED: ,ifY--es a No, (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />XSOIL BORING a HAND AUGER GROUT SPECIFICATIONS: PO 5-2---44-7.--- --C r <br />DOMMENTS: 30 I 1 1:A <br /> <br />,-.7 ---- <br />I OTHER: __1] OTHER APPROX. BORING DEPTH /.5D F-eC--7--- [3 BOLTED TRAFFIC BOX or °STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): t 2 0Y - ---3 s- . 2 T / /7101 —i <br />3--- <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />:ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />igned x .441 Title/Company 6-)r)4/.„5"-±- MCI <br />tint Name 14 /))0, <br />DEPARTMENT USE ONLY <br />)ITE MAP IN UNIT IV FILE, ADDRESS: <br />VORK PLAN DATED: <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 />Date <br />pplication Accepted By <br /> Date Issued 7471-3 <br />Tout Inspection By Date Final Inspection By _ <br />estruction Inspection By Date <br />Area LOP b <br />Date / <br />OMMENTS / CONDMONS: /l/N-,t) bt-L <br />ACCOUNTING ONLY: <br />t <br />AID# cer-ff <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER REQUEST # INVOICE <br />;SO/ F/ °:" ,f-3q T _ i -72/6) qie__ `‘lz 31° SR# 00 "3 ( 2_9 c) <br />:-57 WC -WAIVER _ C-57 Letter of Authorization to sign permi 1/25/02