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�JW;2 PERMIT APPLICATION ORM <br /> ;. E <br /> '10-07 -ENVIRONMENTAL <br /> JOAQUIN COUNTY � 1 <br /> GATION <br /> -ENVIRONMENTAL HEALTH DEPARTMEN UNIT IVB... <br /> '�'? .,.304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PER"'iVICE (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 and the Standards of San Joaquin County Environmental Health Department. <br /> C { t-7,, Assessor$ <br /> WELL Location Z�j(C� �� Cross Street 7Q City T0� Zip 1 w Parcel# j '' <br /> PROPERTY Owner l�N Address +�Z City Zipg�� Phone# -0144 <br /> . L b <br /> C-57 ContractoW 40K%MWdress $59 ity �pgo�Lic#� <br /> �Phone# MoD 94$-I1%9 <br /> Consultant/Sub Cn CAA, j Address * Phone lb rs -2117 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )9NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> OIL BORING 1]OVER-BORE. DIAMETER <br /> WELL# a PRESSURE GROUT <br /> a*Other S GROUT SPECIFICATIONS <br /> COMMENTS: et <br /> t <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> %MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS �t <br /> . [) Q MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION AIR HAMMERIDRIVEN CASING THICKNESS 5dAeA. 4 OTYPE OF CASING: a STEEL PVC Q OTHER: <br /> VAPOR MUD ROTARY DEPTH OF GROUT SEAL_�7 7 TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> AIR SPARGEI OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yes ` No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> (]SOIL BORING a HAND AUGER GROUT SPECIFICATIONS _2,e .k- ee ul-enkh _ <br /> OTHER:_o OTHER APPROX.BORING DEPTH bxr' 1 _XBOLTED TRAFFIC BOX or o STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDW) (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 /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi nces, Rules and Regulations,and all applicable California State Laws. <br /> Signed x Title/Company�_� /'fit he <br /> O <br /> X11 <br /> PrintName_C73A11.' y_9'LLCAf- Date Ott 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S <>- <br /> WORK <br /> WORK PLAN DATED:_ 1c4k, -LAx>L. <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date t 4 Final Inspection By Date '[.4 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3�a1 1ik3A{ t t-vtoL SR# ppA !NLe <br /> C-57 WCC-WAIVER • ' C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />