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<br />\\---) WELL 'ERMIT APPLICATION FaM <br />er IV SAN JOAQUIN COUNTY <br />0 / - ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />0°1 \CiS .N\1 \ 1 ic0\1 (209) 468-3449 <br />PO° ' <br /> <br />)A\ <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br /> <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 and the Standards of San Joaquin County Environmental Health Department. <br />' <br />WELL Location B 5 ha IA> ROCta, Cross Street Fr eni 11.1-*ity Slocictto Zip 9c2 t 5 <br /> Assessors <br />Parcel# <br />PROPERTY OwneZiA0Viihi4 4 & D1(4, Address 44pc Pott igc )6.013 City .1r)t Lion Zip 94207Phone# <br />C -57 ContractorMil'Ate I 1))7 ) i I 1..9 E NV Address ate4 itida7wig CitYielik6duziP Lic#6714/7Phone 3s-158 <br />Consultant / Sub Cntr Advitivccci c44 Address,037.Siew raid CitySiPi Joci Lic# Phone# 03)467404) <br />GIS Coordinates: X , Y , Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />yg\1EW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />0 SOIL BORING # <br />KWELL # I ( Pluti e) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8, ef''MULTIPLE CASINGS? I] MULTI-LEVEL? fl WELL CASING DIA: 2 <br />CASING THICKNESS tit( 40 TYPE OF CASING: l] STEEL KPVC 1] OTHER: <br />DEPTH OF GROUT SEAL*' I A/prOi( TREMIE TYPE TO BE USED: ikAUGERS 13 HOSE <br />GROUT SEAL PUMPED: je'es a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: vel 1.0.44" Codvelett <br />APPROX. BORING DEPTH 1 DO' pOLTED TRAFFIC BOX or 13 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ij ( if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />"Other: <br />COMMENTS <br />DESTRUCTION (choose type below) <br />B OVER-BORE <br />13 PRESSURE GROUT <br />Grout Specifications: <br />TYPE OF WELL INSTALLATION TYPE <br />7AVIONITORING OtIOLLOW STEM <br />13 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR B MUD ROTARY <br />fl AIR SPARGE / Ozone 0 PUSH POINT <br />13 SOIL BORING HAND AUGER <br />[3 OTHER: 1] OTHER <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 State Laws. <br /> <br />'r...t.D/AI:f 8 t 7 ii014,4A4-e-D6.-a Signed x V--Q,--A_A.—.. Title/Company <br />Print Name DPL EL \KA-L.:INABA-0.k Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: t-,Lt c.6 S kr.,“&) 12_0 a ci , c-\ <br /> <br />WORK PLAN DATED: S eAto 1 2_ 00 -2_- <br /> <br />Grout Inspection By tAN.AAAc c/v\ Date (4(5-6:23 Final Inspection By 2C. tr‘,k4A4 Date $fr 03 <br />Area Application Accepted By U,s --tAn.Arr,,i Date Issued <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! ----INVOICE <br />---43S9'0 ° 1%-”2- (If 6/2-03 s!--- 3L( 3 3 -9- <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />Encroachment doc <br /> <br />8/29/02 <br />